A front-page
New York Times story profiling a day in the life of psychiatrist Dr. Donald Levin provided a dramatic wake-up call to the public about the future of
psychotherapy. From dawn to dusk, Dr. Levin sees his patients in 15 minute doses; his current roster includes 1200 patients. He makes his living from seeing patients who are covered by insurance plans that will pay for only
psychiatric medications, not talk therapy. Patients who want to talk about job
stress, marital problems, or general distress must go elsewhere.Not even the receptionist, a former social worker who happens to be Dr. Levin's wife, can provide a sympathetic ear. In fact, Ms. Levin won't even let patients take the time to check their schedules before she makes their next appointments. To do so will mess up her schedule; "This is about volume," she said, "and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we're here two hours longer every day. And we just can't do it." She'll take their co-payments and that's about it.
The story may have come as a shock to most readers who assume that psychiatry, a mental health profession, uses all available tools to address the needs of people who seek relief. However, the practice of limiting psychiatric interventions to dispensing medications is not something new. A 2005 survey cited in the story revealed that a mere 11% of psychiatrists offer any therapy beyond prescribing medications.
Do psychiatrists have a choice? Are they forced into adopting these draconian measures? Apparently some do choose not to succomb to the 15 minute hour. They just won't earn as much. Dr. Levin can make $150 an hour. Dr. Louisa Lance, practicing from her home just 14 miles from Dr. Levin's office, earns $90 an hour for providing talk therapy along with meds. However, according to Dr. Levin, he can't afford to make this sacrifice: "I want to retire with the lifestyle that my wife and I have been living for the last 40 years," he stated.
Dr. Levin's story raises profound ethical issues. According to the Hippocratic oath, physicians pledge to give their patients the best treatment possible. Translated into today's parlance of "evidence based treatment," patients deserve the best treatment that scientific evidence states they should receive.
Increasingly, researchers are discovering that talk therapy, not
medication,
is that best treatment. Extensive research on the outcome of psychologically based treatments shows convincingly that psychotherapy in addition to, or even instead of, medication can be highly effective.
Cognitive-behavioral therapy, a wide range of approaches focused on changing a person's thoughts, is an effective alternative to antianxiety medications,
sleep problems, and
chronic pain. Interpersonal therapy, which trains the person in social skills, interpersonal relationships, and methods of conflict resolution, is particularly effective for a variety of disorders.
There are even more radical departures from medication in alternative therapies such as exercise, relaxation, and meditation. Yes, medications may be needed to manage the symptoms of many psychological disorders. However, to focus only on this one route to treatment is a short-sighted strategy. The side effects of psychiatric medications, and their interactions with a patient's other medications and physical illnesses can, in the long-term, lead to greater dysfunction. Over time, patients need medications just to manage the side effects of their medications, while their psychological needs go unmet.
So why are insurance companies rewarding psychiatrists to prescribe medication instead of psychotherapy or alternative therapies? Are insurance companies willing to pay more for medications than psychotherapy because there's something in it for them? Conspiracy theories suggest that 15-minute psychiatry consults exist so that drug companies continue to receive their huge profits. Ironically, however, according to another New York Times story, it's the insurers who are trying to limit payments to pharmaceutical companies. We are forced to conclude that the insurance companies are simply seeking to maximize their own profits by putting mental health professionals on the medication treadmill. Talk is expensive because it takes time. Drugs can be dispensed in relatively short order.
Prescription privileges are expanding from psychiatrists to psychologists. Two states, Louisiana and New Mexico, now allow prescriptive authority to qualified psychologists. There is a fairly substantial lobbying effort within other states to expand prescription privileges to psychologists. On the plus side, having the ability to prescribe medications to their own patients increases the range of services that psychologists can offer and cuts down on the number of different helping professionals the patient needs to see. The danger is that insurance companies will put psychologists into the same box as their psychiatric counterparts. We will have to wait and see how this issue plays out.
Meanwhile, what can patients do who are caught up in the medication treadmill? Unfortunately, for now, the answer is that you or your loved one seeking help will have to pay more out-of-pocket costs yourself if you want therapy plus medications. Alternatively, here are five useful steps you can take:
1. Seek employee assistance. Find out if your employer has an Employee Assistance Program. Your job security will not be threatened if you use this importance resource. You can use this program to help manage issues that could adversely affect your work and personal life.
2. Find a university of college training center. The sites used to train future clinical and counseling psychologists typically have sliding fees and, depending on their orientation, can help not only with personal but with issues involving children and families.
3. Look for services in your community. Your local non-profit or public human services agencies may offer counseling, group sessions, or access to self-help associations.
4. Explore online resources. The American Psychological Association's Help Center covers a range of useful topics including fact sheets on insurance coverage.
5. Explore alternative treatments. If you are in the care of a psychiatrist or psychologist you should not abandon the treatments they are providing, but at the same time, find out if you can boost your mood or lessen your anxiety with exercise, relaxation, and meditation.
Psychotherapy can and does help, but it takes more than a 15 minute dose.
Visit my site at www.searchforfulfillment.com and be sure to check out the Weekly Focus for more background on today's blog topic.
You can follow Susan on Twitter @swhitbo for daily psychology news, including PsychFacts and PsychTrivia.
Susan is the author of 15 books including her most recent book, "The Search for Fulfillment."
Copyright Susan Krauss Whitbourne, Ph.D. 2011
