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

Psychotherapy: Where Are the Data?

Dr. Strakowski: I agree with John about residency training; it requires an institutional commitment to provide this type of instruction. In our own department, we are fortunate to maintain a strong relationship with our local psychoanalytic institute, in which many of the members are volunteer faculty who love to mentor and teach. We also have a good cadre of cognitive behavioral therapy (CBT) practitioners in the department. To capitalize on these opportunities, we created a resident psychotherapy clinic with a sliding scale out-of-pocket payment schedule, which permits us to teach therapy without entangling with insurance companies. I believe this approach provides a reasonable model within the economic factors that drive training; more relevant is that our example suggests that there are solutions that facilitate psychotherapy training. This approach is just one.

To comment on another point, I agree with Ruth that initial psychopharmacology visits can take an hour just to make diagnostic assessments and establish medication regimens. As patients stabilize, medication follow-up alone can be relatively brief (our family practice colleagues often spend less than 10 minutes with their patients). Consequently, in my own practice with a 30-minute medication/psychotherapy visit (code 90805), it is easily possible to provide 20 minutes or of therapy (I typically do CBT). As Ruth suggests, for patients who need more frequent therapy visits or more complicated therapy than I can provide, I then refer the patient to work with one of the therapists in the department, and we use a team approach. Our financial calculations suggest to us that this approach optimizes the quality of treatment with the revenue generated so that we can afford to actually provide care. However, we don't take a number of insurances because reimbursement is so poor.

One of the problems with psychotherapy is that the research base is insufficient, other than perhaps CBT. We don't really know how to define who will most likely benefit and from which therapy approach and what the right 'dose' is (Why weekly? Why 50-minutes session instead of 25-minute sessions?). I frequently challenge my analytic colleagues to start producing some outcomes data. I don't buy the argument that psychotherapy research is "too hard to do," that I hear so often. It is incumbent on the field to start producing some data.

Dr. Staten: Yes, this raises some critical questions about training and how we best prepare practitioners for the current and future realities of the need for mental health services. I have been involved with, reading about, and implementing primary/behavior health integration. It makes me think that for some people, a model for medication management will be to stabilize the patients and return them to their primary care provider, continue to see them for brief psychotherapy and medication management, or send them to a therapist (and primary care or behavioral health manage medications). One concern I have is that we may be holding on to persons who are stable on medications who could be managed by primary care and then not having enough accessible appointments for patients who need to be seen more frequently while they are being stabilized or are so complex, needing additional or more frequent time. I know this conversation may be getting away from the topic a little, but it does seem to have been a major influence in how/why things have changed.

I completely agree that we must generate some data. There are too few mental health provider resources and the dollars are too precious; we must be efficient and effective in how we deliver services to maximize the outcomes.


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