Despite a trend that started as early as the late 1980s, Gardiner Harris writing in The New York Times yesterday seems to bemoan the fact that most psychiatrists don’t practice psychotherapy any longer.
Perhaps Harris should have interviewed Dr. Danny Carlat, who nearly a year ago wrote about his experiences as a modern psychiatrist (in the The New York Times Magazine, no less). Psychiatrists nowadays are generally poorly trained in psychotherapy, so they spend most of their time prescribing psychiatric medications. (Dr. Carlat’s book, Unhinged is well worth the read for further background about modern psychiatry.)
So I wasn’t sure why I was reading this in the “Money and Policy” section of the Times. Surely it’s not news that psychiatry is no longer practicing much psychotherapy — and hasn’t been doing so for decades. What’s the story here?
It appears to really just be a lifestyle piece about Dr. Levin, a practicing psychiatrist who has had to switch gears mid-career from a psychiatrist who was doing a fair amount of psychotherapy earlier in his career, to one who does nothing but medication prescriptions.
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“Psychiatrists nowadays are generally poorly trained in psychotherapy, so they spend most of their time prescribing psychiatric medications.”
One really wonders how much training really matters when research has shown that paraprofessionals are just as effective as professionals in treating depression and other disorders. It is my view that Master’s and PhD programs in clinical, counseling, or social work are unnecessary. They simply increase the cost for students who want to be a mental health professionals. Instead, counseling or psychotherapy skills should be taught at the Bachelor’s level. This would address student loan debt and decrease the cost of psychotherapy for clients.
“I guess it’s just a lament for “the good ‘ole days,” when psychiatry was the primary clinical mental health profession and didn’t have to share its professional space with clinical psychologists (or clinical social workers).”
Why did you leave out licensed professional counselors? Are clinical psychologists and clinical social workers the only other “professionals” in the field?
MH- Only a few states allow licensed professional counselors
John-
I agree with you, in that I’m not sure what’s new in this article. As you said, the trend of psychiatrists doing less psychotherapy and more med management has been going on for about 20 years. Strange that the NYT would be so behind on this. Perhaps a more interesting angle for the writer to have taken is the rise of clinical social workers, who represent the majority of psychotherapists in this country today — a fact most people don’t realize.
In the addition of the Times that I read, this article was on the front page. That in itself is pretty interesting!
Once people get on meds and become dependent on them, real healing of their underlying psych. issues becomes impossible. You can’t heal if you can’t feel. Most therapists, particularly MD’s – Medical Deities – have emo-phobias. The last thing they want to hear is what people are feeling. They give drugs to pts. so they can get back to something important, like what??????????
Great article, and got me thinking about both sides of the topic. I am currently doing a Grad Dip in Counselling (have a Bach. in Psych)~ one of our reading topics last week was “Is there a difference between counselling and psychotherapy?”
Interestingly, the text was promoting psychiatry as the more expensive form of psychotherapy ~:-)
A mental patient is so full of doubts,grievances & queries when he goes to a psychiatrist that a 15 mt session can barely cover the introduction.He requires catharsis & assurances from his doctor.Unless & until this emotional baggage is removed from his head & heart how can he feel better ?The doctors may be bound by their own limitations on which i am in no position to comment. But under the circumstances para-medicals provide valuable service.
I couldn’t help thinking, when you wrote…
“A great deal of the article is focused on how over-worked and underpaid (for their training) psychiatrists can be — even when they switch to an all-meds practice.
I have news for Harris — that’s all of mental health care.”
I couldn’t help thinking, I have news for Grohol — that’s all of working America!
The problem is that psychiatry is ready to give meds to everybody, without letting them to work on their real issues first. For many once symbols are masked and they have happy (drug induced) with their empty lives, they do not seek further development… until they crash.
And also, Westies want easy fix. Pop a pill be happy ideally. Forget growing, forget karma. Happy!!! Not deal with past, not deal with your life too much besides flowing with the stream.
On support sites we hear “trust your doctor”. How much sense does it make to trust somebody you see for few minutes a month? I could as well as trust the guy in grocery store I shop at. I don’t sometimes know how I feel… so how can somebody who sees me briefly know? By trivial and simplified mood charts? They do not tell as much as they should. Without looking indepth at the issues… more harm than good can be done.
Great post and informative article! Thanks for sharing.. Such a wonderful information. I really appreciate your work. As you said, the trend of psychiatrists doing less psychotherapy and more med management has been going on for about 20 years. Strange that the NYT would be so behind on this. It is my view that Master’s and PhD programs in clinical, counseling, or social work are unnecessary. They simply increase the cost for students who want to be a mental health professionals. Instead, counseling or psychotherapy skills should be taught at the Bachelor’s level. This would address student loan debt and decrease the cost of psychotherapy for clients. A great deal of the article is focused on how over-worked and underpaid (for their training) psychiatrists can be — even when they switch to an all-meds practice.
As WEL member Diana Wyndham said so memorably: ‘My doctor gives me pills to put him out of my misery’.
http://www.pameladenoonlecture.net/the_pamela_denoon_lecture/pamela-denoon-lecture-2008.html
International Women’s Day celebration
The comments addressing drug therapy as somehow inferior to psychotherapy bother me a bit. Psychiatrists who switch to a drug-therapy practice don’t necessarily do so to gain an easy way out. They may do so because the psychotherapy component of mental health treatment is being obtained elsewhere, from clinical social workers and the like. Sometimes, the two work in tandem to provide full treatment for a patient, with one providing therapy and the other handling medications. Not to mention, not all mentally ill individuals need talk therapy; some just have a chemical imbalance. And meds aren’t designed to make you not feel instead of heal as was said above. If your meds are making you numb, then you’re on the wrong meds.
The best therapy I got was from an Licensed Marriage and Family Therapist. Much better than the overpriced psychiatrist. It was a better fit for me and she didn’t pathologize me which I appreciated.
My sister and brother-in-law sought marriage counseling from a Harvard trained psychologist and the therapist was very aloof and blank. One day she looked at my sister and said, “Are you having a feeling?” My sister called me later that day and said, “I hate therapy. I don’t know how you do it.” I told her to ditch the psychologist and find someone who spoke her language and didn’t speak in jargon. They found a great therapist who trained at a local university and it’s been life changing for them. It’s not about the fancy degrees, it’s about the fit.
“Not to mention, not all mentally ill individuals need talk therapy; some just have a chemical imbalance. ”
Is there a test for the said “imbalance”? Until there is, psychotherapy should be always a first line of approach before considering chemical treatment. And most people do benefit from learning coping skills so their “episodes” do not overwhelm them when they come. Pharmaceuticals do not grand you that you never ever have “those thoughts” again. It will not put your life back on track. Pill will not help you to make sense of your feelings (which mostly are result of some real issue… however distorted or exaggerated they are).
Some of the commentators have criticized the New York Times for being “behind the times” in reporting this article. However, I think that what is important here is not the Times documenting a known phenomenon, but rather that the Times is to some degree making us aware of the social implications of this trend. What does it mean to us as a society that the psychiatric profession has virtually entirely abandoned “talk therapy” to concentrate on drugs. As I try to suggest in my blog, it suggests the reification of a profound shift in our understanding of what it is to be human.
What is the old saying? When the only tool you have is a hammer, everything begins to look like a nail. Psychiatry has moved to a medication only practice because the economic reinforcements for doing so were too great to resist.There is no credible evidence to suggest that the explosion of psychiatric medications in the last twenty years has been effective in doing much beyond enriching BigPharma. In fact, the rate of psychiatric disability has skyrocketed as these medications were more widely prescribed. Psychiatrists who, as the article suggests, are often running a medication factory, are not blind to the economic realities. There is a reason why anti-psychotics are the most widely prescribed class of medication in the country – and it is not because there has been an epidemic outbreak of psychosis.
In my location we have a health corporation that I will no longer go to for ANY physical or mental health related issues. They own two hospitals and a wide spread medical group; two counties.
I was referred to one by my psychologist because I needed meds/refills and they are the only resource locally. Before I found my senses I saw one of their psychiatrists for meds/refills. I was only after a month at Johns Hopkins that I realized that I was getting nothing from the corp docs. These docs who are employed by the corp are more concerned about the paperwork required for each and every patient visit than they are listening to the patient. Actually, filling out the paperwork while not listening to a patient.
Two years ago I took it upon myself to find a “self employed” psychiatrist. I drive 45 to 60 minutes each way for a 15 minute appointment, something most patients will not do, but at least I know she cares and listens.
Yesterday, my psychologist, who has known me for many years now and is certified in trauma, and I got into a conversation about the corporation owned psychiatrist and my dislike for them. He commented that he had, prior to my appt, talked with one of those docs and was in a conundrum about finding other resources for his patients. They are rare here around here; so many owned by corporations. He was very unhappy at how uneducated the corp doc “appeared” to him on the phone; one has to wonder if patients even know or can figure this out for themselves.
I agree with a poster above that if the patient is truly seeking wellness, that a psychiatrist in conjunction with a psychotherapist can do wonders.
I am just baffled at how many comments I see here that are claiming that meds aren’t necessary. Hmm, before big pharma came to be, there used to be natural ‘medds’ for such ailments…just think St Johns Wort. ..etal.
Just sayin’ .
It’s not about psychiatrists not doing talk therapy anynore. It’s about psychiatrists refusing or not having the time to work with their patients’ talk therapists in order to properly diagnose them and/or identify the need to prescribe or adjust medications. People with mental health problems are not and should not be treated as lab rats. That is both sinful and shameful and goes against the “Do no harm” oath these doctors must live by.
Mr concern is for the person out there who has real mental health issues and meds can just mask the real problem. What about those who are misdiagnosed on a regular basis and in the mental health system for years until they are properly dianosed? That frightens me for those out there who need help.
Yes, the drugs versus talk debate goes on and on, while mental health ‘issues’ seem more prominent than ever in our increasingly neurotic society. As many people have said before, the therapy industry appears to create more problems than it resolves. If we are serious about reducing the incidence of mental disorders (as opposed to justifying careeers in psychology and psychiatry), we really need to look at the social dimension first.
Individualistic western societies have become lazy, self-obsessed, infantilised and sick. Until we have social institutions which build in principles of contribution, community responsibility and adulthood, mental health will never improve. We have grown collectively mad with too much freedom and too little structure or direction……
I feel that I’m very lucky to have a psychiatrist who does psychotherapy (as well as medication).
In Canada who provides psychotherapy is really important – because with psychiatrists it is fully covered (ie I pay nothing) by the provincial health care system, but with psychologists, unless you are in a hospital – you have to pay. So, psychiatrists not doing psychotherapy does represent a lack of services.
I am surprised only VenusH has commented on Pam Komarniki’s reply to this article.
Pam wrote: “The comments addressing drug therapy as somehow inferior to psychotherapy bother me a bit.”
There is no evidence that psychotropic drug “therapy” is equal to or superior than counseling, in treating mental health problems. Although neither ‘meds’ nor therapy were beneficial to me in terms of healing my mental problems, therapy was far more pleasant and preferable at any time to psych meds.
Pam wrote: “not all mentally ill individuals need talk therapy; some just have a chemical imbalance.”
Pam, it seems, is a little bit behind on her reading of Whitaker, Valenstein, and Moncrieff. So could you tell us please Pam, exactly what ‘chemicals’ are imbalanced in those individuals who don’t need talk therapy?
Pam wrote: “ And meds aren’t designed to make you not feel instead of heal as was said above.”
In my experience, that’s exactly what they do though, designed or not. Not one psychiatric drug in existence that I am aware of has a healing, balancing or regenerative effect on the mind. None of them do anything but “ameliorate symptoms in a clinically useful way”. They certainly do not address and heal mental illness at it’s root.
Pam wrote: “if your meds are making you numb, then you’re on the wrong meds.”
Pam, are you aware that emotion numbing mood-stabilizers and brain/CNS damaging antipsychotics are the mainstay of so-called ‘effective treatment’ for manic depression? Drugs that do not heal and diminish your ability to feel are, in fact, the ‘right’ meds for the condition, according to psychiatrists.
In your opinion Pam, what are the ‘correct’ psychiatric meds for mental illnesses like bipolar disorder and depression? And in what way do your preferred drugs provide lasting healing of a person’s mental and emotional troubles without deadening your mind or heart (and reducing brain cells, causing diabetes, TD, kidney failure, obesity, impotence, etc).
I hope readers of this website will check in on Psychiatric Times over the coming weeks, as we are planning an entire series of pieces addressing the claims and implications of the Harris article. As my friend and colleague Dr. Grohol notes, there are problems with the NY Times article itself, and in my own Op-Ed for Psychiatric Times, I focus on weaknesses in Harris’s reporting.
For example, the study Harris cites showing that only 11% of psychiatrists provide psychotherapy for all their patients is much more nuanced (see Mojtabai R, Olfson M: National Trends in Psychotherapy by Office-Based Psychiatrists. Arch Gen Psychiatry. 2008;65(8):962-970). The study points out that, contrary to the impression created by the NY Times piece, most psychiatrists (59.4%) continue to provide psychotherapy for at least some of their patients.
The Harris piece also perpetuates the “mind/brain” split that devalues pharmacotherapy and ignores the psychodynamic understanding that must accompany medication treatment. Dr. Glen Gabbard has written on this topic, and he will say more in an upcoming piece for Psychiatric Times.
Moreover–and here my view differs from both Dr. Grohol and my Tufts colleague, Dr. Carlat–the best psychiatry residency programs still provide a very rich, robust and thorough background in psychotherapy training (please see Dr. John Manring’s description of the program at Upstate Medical University):
http://www.psychiatrictimes.com/display/article/10168/1579811
Unfortunately, insurance company incentives do tend to drive many psychiatrists away from doing psychotherapy alone. And, our patchwork health care system continues to deny insurance to over 45 million Americans. Most individuals with clinical depression in the U.S. get no professional care at all, much less the benefits of psychotherapy!
Nevertheless, many psychiatrists continue to provide integrated care, in which psychotherapy and pharmacotherapy are both provided, often in sessions lasting about 30 minutes. Indeed, according to Dr. Mark Olfson (personal communication, 3/8/11), the mean visit duration for psychiatric visits has fallen only about 4 minutes over the past 11 years, from 36.8 minutes (1995-1996) to 33.3 minutes (2006-2008).
Finally, though I am no fan of the 15-minute “med check”, there is a great deal more one can do in such a meeting besides saying, “I’m not your therapist!” as the beleaguered psychiatrist in the NY Times piece implies. One can still extend empathy, advice, and clarification, when a patient raises a painful emotional issue during a “med check”-and in my experience, most psychiatrists do so. Even in a short meeting, one can still listen with one’s “third ear”, to use Theodor Reik’s phrase.
Ronald Pies MD
I am a patient who has experienced both kinds of psychiatrist.For 23 years I went to a man who gave me meds, but also talked with me. Believe me when you’ve gone through a mental illness with out being diagnosed for awhile you need someone objective to talk to. After awhile I only saw him every six months. Sometimes I needed to talk, sometimes I was only there a few minutes. He retired. The new one sits and types on his laptop and prescribes meds. I have even gone in there in suicidal depressed stages and manic phases and he just changes the meds. He charges twice as much and my insurance has never paid for it. How can I afford a psychologist when I can’t even afford the guy who just prescribes meds? I really think they need to do a little bit of both.
I am concerned by all the anti-meds sentiment expressed. Remember, before we had psychoactive medications, we had asylums stuffed to the breaking point with people who would never be free again. Once most of the mental hospitals closed and medications were created that helped to stabilize people, the psychiatrists’ jobs necessarily changed to the chemical side of mental illness. .. and psychologist/counselors came into fill the gap.
I am one of the lucky many who has a psychiatrist who works with me on medication issues and listens to me and a psychologist who works with me on other issues and coping skills while working with each other through frequent communications.
If anything, I believe that the mental health improved when effective medications came to be and more therapist started working as there were not enough psychiatrists to meet the needs for counseling. The real problem now is the economic problems for the mental health population as governments cut the budget for them.
I agree with Diana. It’s not if they do talk therapy, but if they talk long enough to figure out the RIGHT diagnosis, and the right medication. Lab rats indeed. When my life fell apart 25 years ago I was tested, had psychiatrist who were genuanly interested in my life being meaniful and functional(in the real sence, not just compliant and non-feeling) with the least amount of drugs possible. Now when asked by my psycholgist to see one for short term medication to get over a rough spot, that 15 min. is not enough for them to listen to me. They label me without beifit of any real tests, and without my psychologist input. End up usually giving me a medicine I told them I can not tolerate and dismiss my concerns and my psychologist as just being a SW. There is a huge differance between the two and there are many good SW out there. In recent years psychiatrist have left a bad taste in my mouth. I only see one when my psychologist feels I’m getting overwelmed and we look together for one that will work with her. Generally it is a indipendant who does not accept insurance. Personally I would prefer one that does not entertain drug pharmacuticals dealers into his/her office. I have found that the older drugs work just as well and with fewer side effects. Sadly the US goverment will not cover most of them. So dispite being on SSDI I pay for seeing a psychiatrist and sometimes the medicine. Some of the recent psychiatrist, desipte only handing out meds,do not understand the serious complications of mixing drugs with medicines for cronic pain. I have to know those and have a very good relationship with my pharmacist, my vigilance has kept me from some serious medicine reactions. I would expect a psychiatrist who’s only job is writing drug prescriptions to know about complictions from multiple drugs. Sadly this hasn’t been my experance. In 10 minutes they give me a wrong diganosis and medications with the potential to kill me. Lab rat indeed, thats why I work with others to find self pay and more open minded Drs. It is a huge burden on a limited income but my ablity to fuction(in the true sense-the ability to do what I can from day to day) and stay alive is worth it. I’m not really sure this new version of psychiatrist fill any purpose. Until they learn to work with therapist and learn that not everyone who sees them needs medication. I don’t see the perpose of having them around, I see no reason a PCP should not be able to perscribe pysch medications untill psychiatrist start doing a better job of diagnosing, learning about medications other than those in the psychratic feild. But most of all learn how to listen when a cleint talks of side effects.
That is so sad. At $100 per hour, 8 hours a day, 20 days in a month, 12 months a year–by my calculation $192,000 per year–the poor things will have SO much trouble paying back their education loans. Maybe they need to go back to college and take a class on money management.
omg he is so right im in and out be fore i can get my coat off its sad i used to get mad as hell i dont my therapist now i know its all of them thank for the read tell mad lol
There were a couple of comments about professional counselors listed above. Currently all 50 states and Puerto Rico have licensed professional counselors. Different states have different names for the license (i.e. LPC, LMHC, LCMHC, etc), but they are all clinicians who have earned a Masters Degree, completed pre and post degree supervised experience and passed a licensing exam.
Ultimately, it all comes down to money. Unless a psychiatrist is in a private practice, the emphasis in all health care is to see the patient for the least amount of time possible and bill at the code that allows for the most reimbursement. An M.D. is paid more, in such a system. Others who now do psychotherapy can be paid less. Even Ph.D. clinical psychologists are often doing less therapy and more testing in such settings. Others such as LMSW (in my state) do therapy. An agency or mental health clinic, hospital, whatever, can bill more for testing.
So, it all comes back to money, in my view.
I do not believe that it all comes down to money in fact I have met several psychiatrist in my venture to get help for myself and I have found that not all doctors or psychiatrists are most concerned with money. I have great compassion for the Mental Health workers even though there are those who are money hungry. I honestly believe that people who want to work in this field have their own issues and this is their way of trying to control their own lives. I was one and this is why I have desire to help others wihout being a professional but by word and deed. Many have had burnout
I wish I knew where you found these new pill pushing psychiatrists. For a few years now, I’ve been trying to find a good psychopharmacologist. Now I’ll just settle for one who is willing to treat with medications and is willing to look them up for instructions on how and when to use them, and who won’t have an ego meltdown if I try to make suggestions or ask questions. Not to be arrogant, but the docs don’t know as much about the drugs as I do. That’s really scary!!!
As someone who has a used mental health services for years, I can say if it came to choosing bettween talk therapy or chemical therapy, I would choose talk therapy every time. When pharma companies have worked out how to by pass psychiatrists with online sophisticated patient diagnostic programmes and e-commerce direct to patients, belive me they will. Too bad shrinks! we will miss you. NOT!
I am grateful and fortunate to have exactly what I need in mental health care. I have an excellent psychopharmacologist who oversees the meds that experience has shown are crucial to controlling my mood disorder. He is sensible, knowledgeable, and conscientious. I also see a very fine therapist who is helpful in dealing with life stresses and in managing my mood disorder.
It’s valuable to have this team approach, with each specializing in what they know best. It’s been successful for me.
I won’t enter too far into the meds/anti-meds debate except to say that I am so grateful that there are drugs available to me that work. They’re not perfect, but having a normal range of human emotions and not feeling excruciating psychological pain all the time makes it possible for me to have a life and to actually use the input that therapists have given me.
“I suspect most professionals today who practice psychotherapy don’t feel like they’re “doing well.” . . . “[M]ost clinical mental health professionals are living a very middle-class, middle-of-the-road lifestyle.”
Reality check. The BLS has the median wage of pyschiatrists at $167,610, and that of clinical/counseling psychologists at $72,540. The former is near as makes no difference the median household income of the top quintile, the latter is 6K below the median of the second highest quintile. Overall median household income is $50,000. The comparison assumes single-wage-earner households, and income/school debt is not considered. It would be a shot in the dark to equate a given income with school debt to a certain income without debt.
Still, all that considered, how are psychiatrists and clinical psychologists at the “middle of the road”? How are they not doing well financially? Not as well as they expected? Not as well as they feel they’ve earned or deserve? Not as well as their parents? Because they are doing a whole lot better than most, and even better than many highly educated professionals. Regarding school debt, be smart about paying off debt instead of jumping into the lifestyle you think you’ve earned.
Of far more concern, most especially to the recipients of psychiatric and psychotherapeutic care, are the changes in industry practice and financing. If these changes make the work more stressful, less effective, and/or less satisfying, that is worth lamenting. But if the main concern for a practitioner in either field is their decline from the upper to upper-middle class or upper-middle to middle class, I would say: 1) nobody else cares, 2) adjust your expectations to reality, and 3) reassess your values and how you’re living up to them. I hope most of them chose their line of work and remain in it because they care about it, and also know how to live within their limits rather than personal and social expectations.