Psychotherapy in Psychiatry: Still Around

Please note that this is one article in a 3 part simultaneous post. Please see Clinical Psychiatry News and Shrink Rap for the other two parts --links below.

Perhaps you've heard the news: psychiatrists no longer have time to listen to their patients. It's all about writing prescriptions for medications and the days of "tell me about your mother" are long gone, or so we're told. The current perception is that large volume practices where patients are seen in a matter of minutes are now standard and acceptable in psychiatry; that it's how many -- if not most -- psychiatrists practice, and that medications and psychotherapy are either/or treatments, rather than complementary.

Is it true that psychiatrists are rushed, uncaring, uninterested, and in it only for the money? Has it all become about how fast a prescription can be written, as if the practice of psychopharmacology is something that can be done quickly, thoughtlessly, and without even knowing the patient? As a past president of the Maryland Psychiatric Society, a former community mental health center medical director, and a general extrovert, I know a lot of psychiatrists. I was curious, and with some help, I put together a How We Practice survey and had the Maryland Psychiatric Society send it out to the members who have email addresses on file.

Psychiatrists were asked how many people they typically see on their busiest day of the week-- please note that this survey was not validated, and data were not collected: it was merely a question we asked in an email survey. The most common answer was 8 to 11 patients. Of the 16% of respondents who report they see more than 21 patients in a day, several noted that they work in settings other than outpatient practices: hospitals, group homes, addiction centers, schools, and settings where patients are seen in groups or with the help of a multi-disciplinary team. Only 10 psychiatrists saw more than 30 patients on their busiest days. We concluded that in Maryland, few psychiatrists have very high volume outpatient practices, or perhaps those who do are too busy to take a survey.

Some patients do very well seeing a psychiatrist for 15 minutes a season (once every three months) and psychotherapy is not necessary. That's not always the case and we know that many patients do better with a combination of psychotherapy and medications. There are patients who may do better seeing a single psychiatrist rather than dividing their care between mental health professionals. Sadly, the insurance industry reimburses best if patients are placed on a conveyor belt to see their psychiatrist. That doesn't make it good medicine, and even when patients get better, some are dissatisfied and angry.

There are several reasons why psychiatrists may practice outpatient psychiatry in a rapid-care model. Participating with insurance plans is a socially responsible thing to do and there are regions of the country where there are very few psychiatrists and restricting practice size is just not feasible. Also, it pays well. That doesn't make it good medicine, nor does it mean that everyone's doing it. There is no one-size-fits-all psychiatry.

Many psychiatrists (70%-- per Mojtabai and Olfson in the Archives of General Psychiatry) see patients for psychotherapy -- if not all their patients, then at least some of them. And often psychiatrists who don't practice psychotherapy still listen and evaluate a patient's symptoms within the context of what is happening in their lives, then take the time to answer questions and explain their treatment recommendations.

Converyor-belt psychiatry works for some, but not for others, and it gives psychiatry a bad name. It is simply not true that all psychiatrists practice this way, that psychiatry has given up on psychotherapy, and that it's all about the medicines. In a field that is hampered by stigma, this portrayal is both wrong and irresponsible, and discourages people from seeking treatment. If that's not bad enough, it also discourages doctors from pursuing careers in psychiatry, and that only worsens the problem.

This is one component of a simultaneous 3-site post on Psychiatry and Psychotherapy. Please see Shrink Rap News on the Clinical Psychiatry News blog for Why Psychotherapy Needs to be Taught (More & Better) During Residency Training

and

Shrink Rap for an overview.

--Dinah Miller, M.D.

Co-author Shrink Rap: Three Psychiatrists Explain Their Work, Johns Hopkins University Press, Baltimore, 2011.

(c) copyright: Dinah Miller, M.D., 2011