The trend is for psychiatrists to see patients for psychiatric evaluation, treatment with medications, and a medicalized version of psychiatric care, while parceling out psychotherapy to non-MD psychotherapists-- social workers, psychologists, licensed clinical counselors, nurse therapists, pastoral counselors (and outside of official referrals, then anyone else who wants to listen...a bartender or two, perhaps the hair stylist).

Those readers who've been following Shrink Rap for a while know that I work in two types of outpatient settings: a community mental health center where I see people to treat their mental illnesses with medications, and a private psychotherapy practice where I use medications but I also provide psychotherapy to patients who want and need it.

Psychiatrists (in those good old days) used to see people for psychotherapy routinely, especially before medications were available.  I was finished with medical school before I even knew that social workers saw clients for psychotherapy. I thought they met with families, worked for agencies, helped with disposition and obtaining benefits, and had a lot to do with foster children and protective services. I believed psychotherapy was the exclusive domain of psychiatrists and clinical psychologists. I simply didn't know.  And if I'd had any inkling that psychiatry would become a field where the expectation was that the doctor would write prescriptions for a rapid succession of people, I would never have entered the field-- of that I'm sure.

I've talked here before about why I think, in a totally ideal world, that it's best for patients to see one person for psychotherapy and medications.  By an ideal world, I mean one where the psychiatrist is skilled at psychotherapy and wants to do it, where the finances work, and where the resources for this are available.  

The reality of the world is that psychiatrists are the most expensive mental health professionals, and in the shortest supply. They are more expensive to train, they often finish school heavily in debt, and there aren't enough to go around. And psychiatric residency programs, for the most part, don't emphasize psychotherapy training-- the resident has to pursue it. A psychiatry resident was recently telling me about a patient who wanted insight-oriented psychotherapy and the resident said, "We just don't have time in residency to do that." For those who know they want to pursue a career in research, spending a lot of time learning to do psychotherapy may not be a wise use of limited time. For those going into clinical practice, the experience of doing therapy during training is essential, even if the psychiatrist does not plan to continue doing psychotherapy.  It's an essential part of the treatment for mental illnesses, and all clinical psychiatrists should have the experience of knowing first-hand what it entails, and what types of problems it helps address, even if they will later choose not to do it.

Some people might go as far to say that it's wrong to have psychiatrists doing psychotherapy, especially in shortage regions where there aren't enough doctors to go around--- a lot more patients can be seen for quick med checks than for 4 times/week psychoanalysis (-- I'm not a psychoanalyst, by the way).

Sometimes, patients start in therapy with a psychologist, social worker,  nurse therapist, or counselor, and they later need medications.  If this relationship is working and helpful, I would never suggest that a patient leave a successful therapeutic relationship for the sole sake of getting medications and psychotherapy from the same professional. 

I believe that people should do what suits them, given the realistic constraints of their environment and their personal preferences.  With regard to psychiatrists doing psychotherapy: I like the work and there remains a demand for it.

This post was adapted from the Shrink Rap post  Should Psychiatrists See Patients for Psychotherapy, published on November 29, 2008

Thanks to Dr. Patrick Barta for the photograph of his office.

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

About the Authors

Anne Hanson, M.D.

Annette Hanson, M.D., is co-author of Committed: The Battle Over Involuntary Psychiatric Care.

Steven Roy Daviss MD, DFAPA

Steven Roy Daviss, M.D., is chair of Psychiatry at Baltimore Washington Medical Center, informatics and policy wonk for URAC, CCHIT, and an HIE.

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