A fifteen-minute med check, a ‘scrip for some Prozac, and you’re outta here, buddy!
You got other problems? Talk to your therapist!
If the front-page article in the March 6 New York Times1 can be believed — and who wouldn’t believe America’s “Paper of Record”? — this is essentially what the practice of American psychiatry has become. But how accurate was the Times’ portrait of outpatient psychiatry? How grounded was it in the best available research? And given the roughly 30,000 psychiatrists in the U.S., how clear a picture can we get by peering through the eyes of one beleaguered practitioner who believes that psychotherapy is no longer “economically viable”?
As an occasional contributor to the Times who has great respect for its journalistic integrity, I’m sorry to say that this story was a disservice both to the Times readership, and to the profession of psychiatry. Although the article may have been a well-intended expose of malign insurance company practices, it amounted to a jaundiced caricature of psychiatric care — accurate in some respects, but distorted in many others. Furthermore, by disparaging the role of psychiatric medications, the Times article reinforced the “mind-body” split that has bedeviled psychiatry for the past 50 years, as Tanya Luhrmann showed in her classic study, Of Two Minds: The Growing Disorder in American Psychiatry.
But before critiquing the Times article, let’s own up to some real problems associated with current psychiatric practice.
It’s true that some psychiatrists have become more comfortable with molecules than with motives. And, alas, as James Knoll MD has recently argued, some psychiatrists have gotten caught up in the “business” of psychiatry and strayed from the path of insightful and compassionate listening.2 The beleaguered psychiatrist profiled in the New York Times piece certainly seems to have lost his way, despite his good intentions.
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
Moreover, other data, omitted from the Times article, contradict the impression that psychiatrists have given up on psychotherapy, or that most meetings with psychiatric patients are just 15 minutes long. For example, Reif et al (2010) found that, in a managed care psychiatric practice setting, two-thirds of claims involved medication management, and two-thirds involved psychotherapy — with an overlap of about 30%.6 The authors concluded that
“Despite potential financial disincentives for psychiatrists to conduct psychotherapy, our findings show that billed claims for psychotherapy by psychiatrists were common… [and] it appears that the broader skill set of psychiatrists is still being tapped, with provision of both medication management and psychotherapy.”6
Furthermore, according to Dr. Mark Olfson, there has been a decline of about 9% in the mean visit duration for psychiatric appointments, in the past 11 years. That may sound like a lot, but it amounts to only a modest change: from 36.8 minutes (1995-1996) to 33.3 minutes (2006-2008) (M. Olfson, personal communication, 3/31/11). This finding also contradicts the impression — strongly reinforced by the New York Times article — that 15-minute “med checks” are now the most common pattern of interaction with psychiatrists.
Although the Times article did not deal specifically with psychiatric residency training, there is a perception in some quarters that psychiatric residency no longer provides adequate training in psychotherapy. A corollary of this view is that younger psychiatrists no longer regard psychotherapy as important; and hence, are at a disadvantage with respect to other mental health professionals, such as psychologists and social workers. In fact, there are sound reasons for being skeptical of this downbeat assessment — or at least for tempering it with more hopeful information.
It is true, on the one hand, that many academic psychiatrists have expressed concern for the diminishing role of psychodynamic psychotherapy in residency training. There are also indications that while over half of psychiatry residents believe their programs provide high-quality psychotherapy training, about 28% express concerns about the adequacy of time and resources in their programs.7
Clearly, there is considerable room for improvement in training. On the other hand, a survey of 15 U.S. psychiatry residency programs (2006-2007) found that among 249 respondents, 82% viewed becoming a psychotherapist as “integral to their psychiatric identity.”8 Fifty-four percent planned to provide formal psychotherapy after graduation. Although this may prove overly-optimistic, given current insurance policies and market forces, the percentage is roughly comparable to the figure of 59.4%, which was the percentage of psychiatrists providing psychotherapy to at least some of their patients, according to the Mojtabai-Olfson study.3
At the best psychiatric residency programs, psychotherapy training is robust and intensive. For example, at SUNY Upstate Medical University where I teach, psychotherapy training starts in the first (PG1) year, with a weekly 2-hour seminar. In the second year (PG2), trainees complete a 6-month course on Learning Psychotherapy, which emphasizes processes common to all evidence-based psychotherapies. PG2 trainees then progress to a 5-month seminar on cognitive-behavioral therapy (CBT). Throughout the PG2 year, residents attend weekly seminars on the “biopsychosocial formulation”, and in the third (PG3) year, trainees enter the clinic, where they receive intensive supervision by a CBT supervisor and a Psychodynamic supervisor, each supervising 1 or 2 selected cases.
Trainees continue seminars with another 24 sessions on Theory and Practice of Individual Psychotherapy, followed, in the PG4 year, with sessions in Post-Freudian Personality Theory and Solution-Focused Therapy. To be sure — the SUNY Upstate program is exceptionally rigorous.9 Nevertheless, there are a number of psychiatry residency programs that provide intensive training in psychotherapy — including but not limited to the programs at Austin Riggs, McLean Hospital, California Pacific Medical Center and Sheppard-Pratt. Baylor College of Medicine teaches intensive psychodynamic therapy, and the Residency Review Committee for Psychiatry requires that three types of therapy must be taught in all residencies: long-term dynamic, CBT, and supportive therapy (J. Manring MD; Glen Gabbard MD, personal communications 3/31/11, 4/1/11).
Finally, one might well conclude, from the New York Times article, that psychotherapy and pharmacotherapy occupy two radically different realms — the “psychological” and the “biological”, respectively. In truth, this is a false dichotomy that has confused the public (and, alas, some clinicians) for the past 50 years. As Dr. Glen Gabbard has observed,
“Both psychotherapy supervisors and seminar instructors often convey that psychotherapy operates in a vacuum apart from medication, which is frequently prescribed by someone else, and that principles of neuroscience exist in a parallel universe with psychotherapy but in no way influence how one thinks about the patient while conducting psychotherapy. We now have abundant evidence that psychotherapy changes the brain .We also know that for many psychiatric disorders, combining psychotherapy and medication provides superior outcomes than either modality alone.”10
Sadly, neither the New York Times article nor the bedraggled psychiatrist it portrayed conveyed these nuances. Instead, pharmacotherapy was likened — incredibly — to an ape swinging a bone!
No doubt there are psychiatrists who practice in thrall to the almighty bottom line. No doubt, they believe they can do so without damage to their own souls and those of their patients. But I have known many more psychiatrists who refuse to sunder mind and body, and whose practice carefully interweaves empathy and chemistry. Many of them were my teachers, and many, my students. These are the real “doctors of the soul” — and even a poorly-researched article in the New York Times will not make them disappear.
Acknowledgments: The author would like to acknowledge the helpful information and perspectives provided by John Manring MD, Mantosh Dewan MD, Glen Gabbard MD, Steve Moffic MD, James Knoll MD, Paul Summergrad MD, Sidney Zisook MD, Robert Gregory MD, Mark Olfson MD, and Sharon Reif, PhD.
- Harris G: “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy”, New York Times, March 6, 2011.
- Knoll JL: Psychiatry: Awaken and return to the path. Psychiatric Times. March 21, 2011. Accessed at: http://www.psychiatrictimes.com/display/article/10168/1826785
- Mojtabai R, Olfson M: National Trends in Psychotherapy by Office-Based Psychiatrists. Arch Gen Psychiatry. 2008;65(8):962-970
- Summergrad P: A Missed Opportunity. Psychiatric Times (in press)
- Gabbard GO: Deconstructing the “Med Check.” Psychiatric Times. Sept. 3, 2009. Accessed at: http://www.psychiatrictimes.com/display/article/10168/1444238
- Reif S, Horgan C, Torres M, Merrick E, Types of Practitioners and Outpatient Visits in a Private Managed Behavioral Health Plan Psychiatric Services. 2010; 61:1066-1068.
- Calabrese C, Sciolla A, Zisook S et al: Psychiatric residents’ views of quality of psychotherapy training and psychotherapy competencies: a multisite survey. Academic Psychiatry 2010;34:13
- Lanouette NM, Calabrese C, Sciolla AF et al: Do psychiatry residents identify as psychotherapists? A multisite survey. Annals of Clinical Psychiatry. 2011; 23:30-39.
- Manring J: No, Psychiatry Has Not Lost Its “Mind”: Here, Psychotherapy Training Thrives. Psychiatric Times, June 2, 2010. Accessed at: http://www.psychiatrictimes.com/display/article/10168/1579811
- Gabbard GO: How Not to Teach Psychotherapy. Academic Psychiatry, 2005; 29:332-338.
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Pies, R. (2011). Has Psychiatry Really Abandoned Psychotherapy? Behind the New York Times Story. Psych Central. Retrieved on March 11, 2014, from http://psychcentral.com/blog/archives/2011/04/03/has-psychiatry-really-abandoned-psychotherapy-the-story-behind-the-new-york-times-story/