Psychotherapy as a psychiatrist

[A Salty Girl]

I'm a med student, and during my psych clerkship I learned that some psychiatrists actually fall in love with therapy and make most of their career doing therapy with patients, and only a small part prescribing.

Is that actually something feasible to do with psychiatry? And if you know people who do it, do they bill similarly to a psychologist or would they bill more? I'm just wondering how patients can afford to have a psychiatrist as a therapist...

The concept is new to me and I just want opinions on it! I'm actually getting interested in psychiatry, but I'm having a tough time seeing myself fulfilled from the profession without being part of the patients therapy.

Do you ever feel like you preach "coping skills over pills" - but are only able to help with the pills part?

Thanks for the info!

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[SmallBird]

I'm a med student, and during my psych clerkship I learned that some psychiatrists actually fall in love with therapy and make most of their career doing therapy with patients, and only a small part prescribing.

Is that actually something feasible to do with psychiatry? And if you know people who do it, do they bill similarly to a psychologist or would they bill more? I'm just wondering how patients can afford to have a psychiatrist as a therapist...

The concept is new to me and I just want opinions on it! I'm actually getting interested in psychiatry, but I'm having a tough time seeing myself fulfilled from the profession without being part of the patients therapy.

Do you ever feel like you preach "coping skills over pills" - but are only able to help with the pills part?

Thanks for the info!

In many settings you can do just what you like. My colleagues and I all enjoy therapy and work for a large system on an inpatient unit - they expect us to achieve high productivity but since 20 minutes of therapy is about the same as an additional follow up, we are all able to spend most of our day doing therapy with patients who really seem to do better for it. I do think it's a bit more difficult in some outpatient settings that have access issues but certainly doable particularly if you have a strong interest and advocate effectively. I am not a very good CBT therapist and don't prioritize learning and remembering protocols but I was very satisfied by my psychodynamic training and use it every day.

 

[Celexa]

It is a less strict dichotomy than you are imagining. Some psychiatrists do end up doing mostly therapy--this tends to be in high end cash only private practice--but also good therapy training can inform and be an important part of your day to day as a psychiatrist in nearly all settings. I do outpatient and consult work and rely on my therapy training every day, even though no patient would call me their therapist.

 

[A Salty Girl]

It is a less strict dichotomy than you are imagining. Some psychiatrists do end up doing mostly therapy--this tends to be in high end cash only private practice--but also good therapy training can inform and be an important part of your day to day as a psychiatrist in nearly all settings. I do outpatient and consult work and rely on my therapy training every day, even though no patient would call me their therapist.

Good to know it can be incorporated!! Thank you so much for the info!

 

[splik]

Is that actually something feasible to do with psychiatry? And if you know people who do it, do they bill similarly to a psychologist or would they bill more? I'm just wondering how patients can afford to have a psychiatrist as a therapist...

Many older psychiatrists who focus on psychoanalytic psychotherapy charge more similarly to what psychologists might charge, however many younger psychoanalytic psychiatrists charge more. I have colleagues who accept insurance and manage to have psychotherapy practices (this may work better in a group practice but also know of some solo psychiatrists who accept insurance). One of my colleagues in the midwest gets reimbursed over $400 per therapy session from insurance (using E&M and therapy codes) but that would be atypical for insurance in my part of the country (unless you are part of a large group that has negotiated good rates). In general, you would make less focusing on therapy than focusing on pharmacotherapy. Many more patients are willing to spend $200-300 per month to see someone vs spending $200-600 every week. Fees and the market for psychotherapy from psychiatrists varies geographically. In addition, while psychoanalytic approaches are having a mini-renaissance at the moment, the demand for psychiatric drugs is much greater than the demand for therapy.

I have a therapy heavy practice and charge more than the typical psychologist in my area. I see some pts twice weekly. Not all of my patients are affluent, though clearly not low SES. What I have found is that some people value spending money on health care, whereas most people do not. One of my patients actually gets reimbursed more from insurance than they pay me lol. Some people also have very good out of network benefits through their school or employer. I have a specific niche which people see me for treatment, and also my patients often want someone to do both meds and therapy rather than split treatment. That said, I also have the occasional patient who I see for therapy only for problems in living who could do well with someone much cheaper but value what they get from me.

This is all to say that it is very doable to have a therapy focused practice, though the earning potential is lower than a similar cash based general psychiatric practice. It is also the case that psychotherapy practiced by psychiatrists continues to be increasingly uncommon. However, as mentioned above, there are still plenty of opportunities to incorporate brief psychotherapeutic interventions, case formulation, and using your knowledge of relationship dynamics within general inpatient, outpatient, C-L and even emergency psychiatry work. Any good psychiatrist will be incorporating this skillset in their work.

 

[A Salty Girl]

Many older psychiatrists who focus on psychoanalytic psychotherapy charge more similarly to what psychologists might charge, however many younger psychoanalytic psychiatrists charge more. I have colleagues who accept insurance and manage to have psychotherapy practices (this may work better in a group practice but also know of some solo psychiatrists who accept insurance). One of my colleagues in the midwest gets reimbursed over $400 per therapy session from insurance (using E&M and therapy codes) but that would be atypical for insurance in my part of the country (unless you are part of a large group that has negotiated good rates). In general, you would make less focusing on therapy than focusing on pharmacotherapy. Many more patients are willing to spend $200-300 per month to see someone vs spending $200-600 every week. Fees and the market for psychotherapy from psychiatrists varies geographically. In addition, while psychoanalytic approaches are having a mini-renaissance at the moment, the demand for psychiatric drugs is much greater than the demand for therapy.

I have a therapy heavy practice and charge more than the typical psychologist in my area. I see some pts twice weekly. Not all of my patients are affluent, though clearly not low SES. What I have found is that some people value spending money on health care, whereas most people do not. One of my patients actually gets reimbursed more from insurance than they pay me lol. Some people also have very good out of network benefits through their school or employer. I have a specific niche which people see me for treatment, and also my patients often want someone to do both meds and therapy rather than split treatment. That said, I also have the occasional patient who I see for therapy only for problems in living who could do well with someone much cheaper but value what they get from me.

This is all to say that it is very doable to have a therapy focused practice, though the earning potential is lower than a similar cash based general psychiatric practice. It is also the case that psychotherapy practiced by psychiatrists continues to be increasingly uncommon. However, as mentioned above, there are still plenty of opportunities to incorporate brief psychotherapeutic interventions, case formulation, and using your knowledge of relationship dynamics within general inpatient, outpatient, C-L and even emergency psychiatry work. Any good psychiatrist will be incorporating this skillset in their work.

This is such a thorough explanation. Thank you!!

 

[comp1]

You can definitely do therapy. I would just say that for most psychiatrists, it's harder to make money this way. I don't mean just in terms of developing the business, although that's a huge part of the difficulty since you aren't likely to get much training in launching a business from a bunch of academics. I mean also in terms of education. Psychiatry residency is not, generally, focused on therapy. It varies by program, of course, but generally it's part of a list of requirements, not a focus. I think most importantly, for me at least, therapy was a heck of a lot more emotionally draining than developing psychopharm regimens or doing discharge planning for inpatients. You have to some left for yourself at the end of the day. So yes, you can do it and statistically those who do end up doing it actually make more money, but I would argue they also work a heck of a lot harder.

 

[Candidate2017]

You can't be a good psychiatrist without good therapy training. My therapy training informs how I interact with patients.

That said, I don't do full on therapy because I work for large systems, i.e., I earn my keep via 3rd party payors/insurance. As such, I'd estimate a good 80-90% of the therapy skills I learned are wasted clinically (though 100% valuable to me in dealing with things like countertransference). The main demand for psychiatrists is one's utility as a physician: diagnosing, prescribing, dealing with interactions and side effects.

To work mostly as a therapist, you'd likely have to have your own PP, working with atypical patients who do not have severe mental illness and who do not want a pill for every ill.

 

[comp1]

I think the poster above does bring up a good point. You will get good training on how to incorporate psychotherapy in medication management, including on medical floors. I do view that as somewhat different from formal, dedicated psychodynamic psychotherapy, CBT or other modalities, however.

 

[Celexa]

I think the poster above does bring up a good point. You will get good training on how to incorporate psychotherapy in medication management, including on medical floors. I do view that as somewhat different from formal, dedicated psychodynamic psychotherapy, CBT or other modalities, however.

I think this is an artificial distinction. The training I had in longitudinal therapy is the foundation of applying those skills in short term, higher pressure situations. I'm never going to do weekly therapy with a patient again but I don't think I'd be nearly as good a psychiatrist if I hadn't, even though now I deploy my therapy skills in different contexts.