Dr Robert London

We Must Take Back Talk Therapies

Clinical Psychiatry News - Volume 37, Issue 8, Page 12 (August 2009)

The number of psychiatrists who provide psychotherapy is on the decline. Numerous studies have pointed out that psychiatrists are more focused on medication management, and that we typically hand over our psychotherapy patients to nonmedical therapists.

In addition, the general impression among many patients seems to be that it's best to go to psychiatrists for medications and therapists to do talk therapy.

It hasn't always been this way. For decades, psychiatrists were the sole providers of psychotherapy, with psychoanalytic or analytically oriented therapy forming the mainstay of clinical practice.

The reasons for the decline in the number of psychiatrists who do psychotherapy include the poor level of third-party reimbursement for “talk therapy,” the success of pharmacologic treatments alone, and the view that reaching more patients by providing 15-20 minutes of medication management for three to four patients an hour is a more efficient method of care and affords better payment. From the third-payer perspective, nonmedical therapy is often less expensive for them, even though it is not necessarily better care.

Talk therapy (which I believe includes cognitive-behavioral therapy, behavior modification, and relaxation) does not have to be open-ended. It can be codified, goal-oriented, and short-term. One of the first psychiatrists to use cognitive therapy appears to be Pierre Janet, who, more than 100 years ago in his L'Automastime Psychologique, advanced the idea that thoughts can be challenged and that perceptions leading to mental problems can be reversed. It was not until Albert Ellis, Ph.D., in the beginning of the second half of the 20th century, and Dr. Aaron Beck a decade later clearly showed the positive, short-term successful effects of cognitive therapies that some recognition occurred.

After World War II, the competition for psychotherapy increased with the number of psychologists who shifted from research or animal studies to a more therapeutic role, and the possibilities of referrals to them and of them providing direct psychological care increased substantially. In direct competition with the psychologists was the burgeoning group of social workers who became mental health therapists—not to mention others who do practiced psychotherapy based on a wide variety of training and techniques, but who nevertheless provide mental health care.

The area of psychotherapeutic care appears to be in disarray at the moment, with so many different therapists offering different treatments and psychiatrists not offering psychotherapy. But psychiatrists should be in the leadership role rather than just focusing on medication management.

One new and interesting development is that psychiatrists are offering limited education to primary care physicians (PCPs) on how to medicate psychiatric patients. What kind of message do we send to our profession and to the residents in 4-year training programs when we offer 1- or 2-day courses in how to diagnose and treat psychiatric disorders by nonpsychiatric doctors?

I don't see any other specialty following this model. If the model is to provide better care for less money, as any practicing physician knows in any specialty, it does not happen that way. So as the PCP treats psychiatric patients with medication, it's not uncommon for the therapists doing split care to turn to the PCP for advice or guidance—then what becomes of psychiatry, the specialty that pioneered, focused, and led in caring for mental disorders?

There might be some hope if we can start by redefining psychiatry based on a model similar to other medical and surgical programs. That is, let's update psychiatric residency programs to include intense training in behavior modification, the cognitive therapies, and hypnotic/relaxation techniques. Psychiatrists would then emerge with therapies that are effective, codifiable, and very often time limited.

I spoke with Dr. Sudeepta Varma, a young psychiatrist who is the medical director of the World Trade Center Mental Health Program at Bellevue Hospital in New York City, and she swears by cognitive-behavioral therapy (CBT). She says training programs teach CBT but generally fail to offer online experience in using these techniques, so psychiatrists in training are unable to become expert at these successful treatment methods.

In addition, Dr. Varma points out, the trainees she knows are more interested in the traditional psychodynamic therapies—and those who might be interested in CBT have to elsewhere to get training.

Successful behavior techniques such as reciprocal inhibition, systematic desensitization, guided imagery, flooding, assertiveness training, and modeling must be taught in psychiatry training programs. These psychotherapeutic techniques are an important part of the psychiatrist's armamentarium. If psychiatry is going to save itself, we must take back these therapies and provide leadership in using them.

About 6 years ago, I conceived the idea of The Psychiatrist's Toolbox, and we've had a great run. However, this is the last Toolbox. Watch for my byline on CLINICAL PSYCHIATRY NEWS' Opinion pages, where I will be featured from time to time as an expert commentator on timely psychiatric/medical issues. Keep in touch.

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