If you follow the news, you know it’s a bad time to be a psychiatrist. I’d say almost as bad as being a Catholic (especially during the sex scandal … holy Jesus).
Apparently they no longer really care about their patients. They are a bunch of greedy Mr. Krabs. They have abandoned psychotherapy, only to pass out samples of the latest drug so that they can get their free lunch from big Pharma. (My sister used to make them … they’re quite good!)
And then along comes one of my favorite psychiatrists, Ronald Pies, M.D., to set the story straight. In a World of Psychology post earlier this week, he dissects the front-page article in the March 6 issue of The New York Times.
Pies cites some statistics that, yes, indicate there is less psychotherapy today performed in psychiatric visits; however the same studies also maintain that almost 60 percent of psychiatrists are providing psychotherapy to at least some of their patients. And there are a few other complexities regarding the numbers that the Times failed to consider.
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I never met a psychiatrist that did any psychotherapy. After the initial one hour evaluation period, it was simply stop in for 10 minutes, get the refills, move on. That is why I quit going to a psychiatrist and have my primary care physician handle meds for me. Are psyciatrists trained in psychotherapy?
My psychiartrist told me to expect my first appointment with her to be an hour. Which it was. If she feels that you need more time with her at your appointment she gives it to you. I never get away with a statement of “good” when replying to “How are you?” She keeps me on my toes and takes health insurance. I guess I am lucky.
Mary – you definitely found a good one.
I like psychiatrists!
One of my best friends is one of the best!
Samuel Lopez De Victoria, Ph.D.
http://www.DrSam.tv
Well, Psychiatrists can be happy they did not reach the “Muslim” status in the media yet. I have hard time feeling sorry for their reputation too (and I bet they do laugh at the way to bank, so I am not wasting my tears and sympathy here).
A digression to begin: Mainstream Catholic parishioners are held in high respect by the media. It is the Catholic priesthood and hierarchy that is under media scrutiny, mostly for not policing its own.
As for the psychiatrists, even Dr. Pies would agree that more than 40% of psychiatrists do no kind of therapy whatsoever. They are, essentially, psychopharmacologists.
I would guess that when one factors out the populated-by-the-worried-well-who-can-still-afford-psychoanalysis territories of the Bos-Wash and San-San corridors, well over 50% of the psychiatrists don’t do therapy. That is, in well over 90% of the land mass of the country, psychiatrists are closer to the NYT-story model than to the Pies model.
Can it change? Certainly. Do I hope it changes? Absolutely. Do I have huge respect for psychiatrists who do therapy? Always. But right now, I think those are the facts.
Hi, Therese–Many thanks for your clear voice and sense of fairness! Just to address a couple of points in some of the earlier comments: psychiatrists most certainly do receive intensive training in psychotherapy, though this varies in quantity and quality among residency programs [please click on the link to my article to read about some of the best programs].
As to the notion that 40% of psychiatrists are merely “psychopharmacologists”, that conclusion rests on the assumption that no psychotherapy goes on during a “med check” of 15-30 minutes. But this isn’t necessarily so. As Dr. Glen Gabbard has noted many times, even in the space of 20 minutes, psychotherapy goes on, and psychiatrists don’t instantly forget their training in cognitive-behavioral, supportive, and psychodynamic techniques–at least, not the best ones. No, it’s not what Freud would have called “psychotherapy”, but it is more than just handing out a medication.
Except in the most straightforward cases, half the “medication” session may be spent exploring the patient’s fears, fantasies, or misunderstandings about what the medication is intended to do; e.g., “I feel less depressed, but I’m still not happy with my life…I thought the medicine was supposed to help with that.”
All that said, I am certainly not pleased with the decline in the use of psychotherapy by psychiatrists, and I very much hope that with a better health-care system, we can begin to gain back some of the ground we have lost.
Thanks again, Therese!–Best, Ron Pies MD
I respectfully disagree with the above colleague’s position, offering that one can provide effective psychotherapuetic interventions in a 20 minute visit. Furthemore, I doubt that even 50% of psychiatrists commit to seeing patients for a full 20 minute period to justify that time period definition.
What Dr Pies and other alleged Key Opinion Leaders need to be completely frank and transparent with the mental health population is simply this: what is the standard of care for the illness being presented to the provider and how can the patient access said interventions to the fullest without being compromised by providers first focused on reimbursement and second availablility.
By the way, perhaps Dr Pies would be kind enough to briefly clarify his position on defining the needs to treat grief with medication and psychotherapy. Note I call the issue grief, not depression, which are two different presentations, at least the way I was trained and continue to see the problems in my office even as of 2011.
I appreciate Dr. Hassman’s collegial note, and I believe he raises several important issues that require clarification. I believe that in most respects, our views on psychotherapy are not as far apart as might be supposed.
First, it is important to note that the most recent available data suggest that the mean visit duration for psychiatric visits (2006-2008) is about 33.3 minutes, compared with about 36.8 minutes in 1995-96 (Dr. Mark Olfson, personal communication3/31/11). Thus, the infamous “15 minute med check” is probably not representative of psychiatric practice in general. That said, I believe that whether or not a psychotherapeutic intervention is “effective” depends on many factors—not simply on the duration of the session.
If the psychiatrist is providing medication to a patient with, say, generalized anxiety disorder, it may be quite feasible to teach an effective relaxation technique to the patient during a 10-minute portion of a 20-30 minute session. On the other hand, I suspect Dr. Hassman and I would agree that a suicidal patient with Borderline Personality Disorder, presenting with “diffuse primitive rage”, is likely to require at least a “50 minute hour” in order to benefit from a psychotherapeutic intervention.
I do agree that our interventions should conform to the standard of professional care propounded in “expert consensus guidelines” and the research literature on a particular condition—-and certainly should not be dictated by financial imperatives, insurance company rules, or mere convenience. That said, I would recommend to Dr. Hassman’s attention the book, “Very Brief Psychotherapy”, by Dr. James Gustafson. Dr. Gustafson, using psychodynamic principles, shows how even very brief interventions of a few minutes can indeed be effective, in carefully selected cases. Of course, this requires considerable depth of skill and experience.
With regard to Dr. Hassman’s query about “grief”, this is both a simple and a very complicated issue. The “simple” position—which Dr. Sidney Zisook and I have articulated in many postings and publications—is that “ordinary” grief is a normal, adaptive response to profound loss. It does not require “treatment”, and so, the issue of medication vs. psychotherapy is moot. Most persons experiencing ordinary grief in response to loss will heal on their own, with time, if given reasonable support and empathy by friends and family.
The matter becomes more involved, however, in cases of so-called “prolonged” or “pathological” grief, in which the person’s grief becomes all-consuming and interferes with the routine activities of daily living. Then there is the matter of so-called “bereavement-related depression” (BRD), in which the person meets all symptom and duration requirements for Major Depressive Disorder, shortly after the death of a loved one. These individuals may often require professional help, and there is evidence that both psychotherapy and medication may be effective. For more on these issues, Dr. Hassman and others may want to see the long exchange between Dr. Michael First and Dr. Zisook and me. BRD remains a very controversial issue, and impinges on the so-called “bereavement exclusion” that now faces possible elimination in DSM-5. The link is:
http://www.medscape.com/viewarticle/740333
Dr. Zisook and I would agree entirely with Dr. Hassman that ordinary grief is a fundamentally different condition than clinical depression. We discuss the differing “inner worlds” of grief/bereavement and depression at the following link:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2922362
Finally, I would add that debates about 15-minute checks versus psychotherapy run the risk of obscuring the more serious problem affecting health care in this country, including mental health care; namely, the lack of affordable and accessible care by highly-qualified professionals. For example, only a small proportion of those with major depression ever receive proper assessment and treatment in the U.S., largely due to barriers in provision of health care.
I appreciate Dr. Hassman’s questions and I hope I have clarified my positions on these matters.
Best regards, Ronald Pies MD
Good article but unfortunately takes the whole biomedical paradigm for granted…(i.e. presumes concepts such as psychiatric disease[s] and [Kraepelinian] diagnos[es] to be literally true and concretely real)…perhaps there will always be controversy because of the practice of seeing psychological disorders as medical issues in the first place? (Freud wrote an entire book against having psychoanalysts be medical professionals “The Question of Lay Analysis”]).
I see my orginal psychiatrist once every few months for 45-minute psychotherapy. He no longer writes prescriptions because I see a colleague of his at a different clinic for weekly 50-minute psychotherapy with medication management. I negotiated this arrangement because both the original psychiatrist and my original therpist are nearing retirment, and I wanted to consolidate. With Medicare, it’s less than profitable for the practice, but it’s an agreement we made 2.5 years ago. I also occasionally see the therapist, whose approach is somewhat different than either psychiatrist.
The 45-minute sessions are mandated by that clinic as maximum therapy time.