In Therapy

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Is Psychotherapy Dying?

Is Psychotherapy Dying?

I've heard the murmurs for a while now. My professors back in graduate school often bemoaned the decline of private practice. They said managed care and Big Pharma threatened to render psychotherapy obsolete (to a room of aspiring clinical psychologists, no less). Glancing at the msnbc.com headline Monday, you'd think those predictions were coming true.

The article, titled: "In era of pills, fewer shrinks doing talk therapy" suggests psychotherapy is losing ground to medication in the treatment of psychological disorders. It refers to a study published this week in the Archives of General Psychiatry illuminating a trend: American psychiatrists are moving away from psychotherapy in favor of psychopharmacology. The study reports statistics showing fewer patients going to psychiatrists for psychotherapy and fewer psychiatrists providing therapy. The article cites "the expanded use of pills and insurance policies that favor short office visits" as possible reasons for this shift.

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So is psychotherapy dying? Some assorted thoughts I have on the topic:

- Not necessarily; at least this article doesn't support that idea. All it says is fewer people are going to psychiatrists for therapy. With a growing number of masters and Ph.D. level clinicians providing psychotherapy at lower fees than MD's, I'm not at all surprised patients are going elsewhere. Also, psychiatrists earn more for medication management than therapy, so it makes financial sense for them too.

- According to Psychology Today's own 2004 study, more than 27% of all adults (an estimated 59 million people) received mental health treatment in the two years prior. Of this group, "47% report a history of medication, but no therapy; more than a third (34%) report a history of both medication and therapy; and 19% report a history of therapy, but no medication." That's 30 million people in psychotherapy during that two year period. Medication clearly has an edge over therapy, but therapy appears to be alive and well.

-However, the article does raise a question for my blog colleagues (blolleagues?) over in the Psychiatry department: is psychiatry dying? If psychiatrists are losing their chops or interest in therapy, and psychologists obtain prescription privileges (as a passionate segment of psychologists are lobbying), psychiatry could face an identity crisis.

-I need to make a disclaimer here. A psychologist commenting on psychiatry is professionally analogous to the Red Sox commenting on the Yankees. There's a tenuous relationship at times between the two fields. I have nothing but respect for my psychiatrist colleagues, and personally have no desire to prescribe. Since I've been around I've understood psychiatrists to manage medication and only occasionally provide therapy. And if they did provide therapy, it was psychoanalytic. I personally adhere to psychoanalytic principles and understand the process and outcomes are not always amenable to insurance companies' desire for quantifiable progress. There's no medical code for Resolution of Oedipal Conflict. This may help explain why "fewer shrinks [are] doing talk therapy."

- Who gets to be called "shrinks" anyway? I thought all therapists were shrinks. I'm a clinical psychologist, and I've been called a shrink for years. This article implies only psychiatrists are shrinks. Now I'm having an identity crisis.

So is therapy going the way of the VCR? Will mapping the genome, designer pharmacology and Internet-based treatment render the couch obsolete?

In my incredibly biased opinion, no. I think therapy is here to stay. At least long enough for me to save up money to retire without the benefit of Social Security. Here are five reasons I believe therapy will be around a while:

It's natural: In this era of organic food, hybrids, naturopathic medicines, vaccine phobia, carbon footprints and Whole Foods, we're more wary than ever of what we put in our bodies. We have a treatment for psychological problems that doesn't involve ECT or chemicals, and is generally understood to be as effective: therapy. It's sitting and talking with another person, the most natural interaction you can imagine - no preservatives, no carcinogens, no mercury, no child labor, no cholesterol, no fossil fuels. I'd call it green, but you still need to drive to your appointment.

It's relational: We're creatures in need of contact. As much as we love technology, human connection is essential. A great number of psychological problems are created or exacerbated by our significant relationships. Would it not make sense that the treatment would be relational as well? With our significant relationships dwindling by a third over the last 20 years, it seems relationships are more essential than ever.

It's old school: Therapy has really only been around for the last century, but it feels like we have a deep therapy tradition in our culture. For many emotional issues, people first choose therapy. Couples wanting to get married or divorced tend to go to therapy. People looking to find meaning in life go to therapy. Turn on the TV and you'll find Tony Soprano, Bob Newhart and Betty Draper all participating in therapy. For better or worse, it's woven its way into our culture.

It's evolving: It would be difficult to eliminate a field that is so eager to adapt to the times. Flipping through the program for the upcoming APA conference, I'm struck by the number of new, innovative, creative theories and applications being unveiled. Generation X & Y shrinks aren't ditching psychotherapy, they're using research and technology to improve upon it.

It works: Insurance companies might not want to pay for it, but they can't deny its effectiveness. If it ain't broke....

 

Ryan Howes, Ph.D., is a clinical psychologist, writer, musician and professor at Fuller Graduate School of Psychology in Pasadena, California.

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