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

A Reimbursement Quandary

Dr. Gunderson: I often get impatient with therapies where there is not visible progress. Mostly, though, ineffective therapies don't endure. There is, in any event, something inherent in the therapeutic exercise that is valuable in the absence of outcome data. Patients deserve to be listened to, and they remain our primary resource for their understanding. If those processes get short-changed because we don't have outcome data, then who gains what? If they get prolonged because a doctor or patient likes it too much, who loses? Third party payors? Certainly. Psychiatry's integrity? I'm not so sure. Healthcare costs? Probably not, if I remember correctly from a Consumer Report a few years back.

With respect to psychoanalysis, I think it can enrich one's life but it is not a treatment for the mentally ill. It does not belong in the reimbursement debate.

While the current growth of evidence-based therapies (EBTs) provides a rationale for reimbursement and can assure more uniform benefits, these studies rarely if ever measure a comparator therapy provided by clinicians with any extended experience working with the designated patient type. It was therefore instructive that in a large multisite randomized controlled trial (RCT), the borderline patients treated by a self-selected psychiatrist with 5 or more years experience did as well as those treated with good quality dialectical behavior therapy.[3] My point is that dedicated therapists get better with time and learning the specifics of an EBT expedites the learning, but their effectiveness doesn't mean that such training is necessary.

Do others think that reimbursement for psychotherapy should be limited to instances where the therapist has been certified as competent in an RCT-validated therapy? Very few therapists could meet this standard.

Dr. Staten: Two thoughts to this discussion are one having to do with basic preparation in psychotherapy and the other with utilization of psychiatric services, specifically, the medication/psychotherapy brief visit.

Our discussion leads us to the conclusion that all mental health providers need some level of psychotherapy training in their basic programs, including psychiatrists. There are 2 reasons for this. The first, I mentioned before: to continue the strong foundation of common values, experiences, and understanding across mental health providers. Training and education in psychotherapy not only provides a skill but also instills certain beliefs in the human experience and in the importance and dynamics of the therapeutic relationship beyond basic interpersonal communication. I hope we will hang on to this. When the psychiatrist does not have that background, it changes the dialogue among the disciplines but it doesn't add much to the mix beyond the family practice physician, except additional expertise in the myriad of medication combinations. I would hope that someone seeing a psychiatrist for medication management (even for the billing code 90805) would have a somewhat different experience than a visit to the family practice provider. Hopefully, that does not sound too harsh -- I really don't mean for it to. I work with 7 or 8 psychiatrists from fairly new to very seasoned and they all have roots in psychotherapy, so I am not completely sure how it plays out when that is absent or minimal.

This brings me to the question that John posed regarding the need for certification in specific therapeutic modalities for there to be reimbursement. I am not sure there is a simple answer to this question, and there are variables to be considered. Many of the psychotherapies build on some basic concepts and skills and can be enhanced or broadened to other EBTs through a variety of formats: reading, DVDs, supervision, CME, etc. While others (for example, eye movement desensitization and reprocessing) require some very specific knowledge, background, and practice to be safe and effective. There would be very few therapists or practitioners who could meet the standard for being certified -- think of the twist and turns some of the therapies have; would one have to be certified in each of these nuanced modalities?

I appreciate John's comments on the research behind our work, the problems with the way we have conducted RCTs , and the limits of these trials to real patients, providers, and situations. The exclusion criteria alone can make application to real, complex patients with complex lives difficult. Of course, I support creating a scientific base for what we do, but taking it to the next step with adequate comparisons and translating into practice settings is critical. Sadly, I have known therapists to avail themselves to many certificate programs while lacking some of the basics, which allow for connection with the patients. There has to be some balance in the approach to this part of the question.

I can't even really weigh in on the psychoanalysis question. One of the things I am becoming acutely aware of -- especially, when we keep persons too long in therapy or under psychiatric care -- is are we creating a self-image that takes on an "illness image" that might not be healthy for the patient? When could some of these clients be stabilized and returned to their primary care providers for continued treatment? These are great questions. I think finding some answers would help us get patients to the right providers and the right treatments and more effectively and efficiently utilize our limited mental health resources.


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