Where Has Psychotherapy Gone?

Stephen M. Strakowski, MD; John G. Gunderson, MD; David J. Reinhardt, PhD; Ruth R. Staten, PhD, APRN-CS


August 18, 2011

In This Article

Editor's Note: Medscape recently invited Dr. Stephen Strakowski to moderate a virtual discussion between psychiatrist John Gunderson, MD, psychologist David Reinhardt, PhD, and mental health nurse practitioner Ruth R. Staten, PhD, APRN-CS, on the decreasing use of psychotherapy by psychiatrists and how this development is impacting patient care. What follows is a transcript of their discussion.

Where Has Psychotherapy Gone? Introduction

Stephen M. Strakowski, MD: As you all are aware, studies suggest that psychotherapy is becoming an increasingly rare part of many if not most psychiatric practices.[1] What factors do you think are responsible for this decline, and is this change in practice important? How does it affect psychiatry's role and reputation in the United States?

Ruth R. Staten, PhD, ARNP-CS: It seems to me there are at least 3 factors that contribute to the changes in psychiatry: (1) demand/need for services, (2) complexity, and (3) economic/financial.

With an increased number of persons with psychiatric/behavioral disorders and a decline in the number of providers, the time that patients have to wait to see a psychiatrist can be unreasonably long -- sometimes up to 3 months. There are some areas of rural America that have few if no providers, but we all feel like clients should have timely access to care. This critical shortage is particularly true for medication management. Psychiatrists have had the struggle of having clients or other healthcare providers begging for persons in need to be seen more quickly. Additionally, once the client is in the care of the provider/psychiatrist, appointments may be needed on a fairly frequent basis, until the client is at least out of a crisis and moving toward stability.

Though caring for persons with psychiatric illness has been complex, with the multitude of medication treatment options and the degree of chronic illnesses and medications that often accompany those illnesses, providing medical management can be quite demanding. Evaluating their medical conditions, assessing medication interactions, and monitoring psychiatric, physical, and laboratory findings are quite time consuming. The majority of an hour session can be taken up with evaluation of these issues. This leaves little time for traditional psychotherapy. Additionally, we have some very specific psychotherapies that require a fair degree of time and are often "manualized" to be true to the therapy. One has to wonder if the more one has time to deliver these therapies, the better they would become, so those who focus solely on these therapies might be the best able to deliver them.

The economic/financial considerations are a constant battle -- changing regulations and reimbursements, the cost of just doing business and seeking reimbursements, the emphasis of reimbursement on procedures rather than specific outcomes -- and have fueled the need to maximize one's income just to cover expenses. There was an interesting article in the New York Times recently recounting a long-time psychiatrist's journey into 15-minute medication checks and all the thoughts and considerations that took him to that point.[2]

Having said all of this, I cannot imagine, and I do not hear from my colleagues, that given a perfect world, they would choose this situation of managing medicines and doing very little psychotherapy. It just doesn't seem very rewarding in the sense that we were drawn to this work because it connected us to people in ways that other areas of healthcare may not.

John G. Gunderson, MD: Ruth nicely identified 3 reasons for the change in psychiatric practice. I would add a fourth: resident training.

Training of residents occurs within institutions governed by managed care thereby relegating most interventions to changing or initiating medications. This then is what gets taught, this becomes the role modeling, and this is how institutional jobs are defined. Confounding this has been the fact that biological/psychopharmacological research has been the major avenue for gaining academic credentials and advancement, so that academic departments rarely have places for those who are primarily psychotherapists -- certainly not in positions of power. Once again, modeling and incentivizing residents towards psychopharmacological practices.

Having said this, I do not believe that most modern residents are different than those I did my training with 40 years ago. Most still choose psychiatry because it promises more personal and closer relationships with patients and a better understanding of the human condition than any other field of medicine. While psychiatry today does far more good and far less harm than when I started, it has done itself a disservice by not making the necessary effort to retain psychotherapeutic competence as a requirement of training. The ex-Massachusetts General Hospital/McLean resident in the New York Times captured this. He hadn't learned during his training that listening to his depressed patient's sad story would enrich his practice and be very helpful to his patient.

David J. Reinhardt, PhD: I did an informal telephone survey for the National Alliance of Professional Psychological Providers researching the length of time involved to secure a new patient first appointment. I was gladdened that insurance coverage was not an important determinant; in those instances when we stated there was no insurance, we were not brushed off but given cost information and an opportunity to book. Time to first appointment ran a minimum of 6 weeks to as much as 3 months.

The knowledge of physical contributors to psychiatric disorders and the specialized knowledge needed to treat have mushroomed in the last 40 years, and so has our understanding of psychological insights and treatments. We are well past the age of the pastor/counselor as effective psychotherapist and have refined the application of a much larger "grab bag" of tools and techniques. As with physical medicine, the volume of knowledge demands increasing specialization if we are to be truly competent.

Insurance companies have limited reimbursement for psychotherapy to brief therapy, 4-8 sessions, which has not been, in my opinion, a bad thing. Still, this intense level of interaction, in addition to medication management and other physical medicine issues, seems more than can be accomplished in a therapy hour, and it is unlikely clients or insurance companies would agree to reimburse for longer sessions.


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