talk therapy

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same21

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I think this article falsely portrays psychiatry as an either/or dichotomy between old-style psychodynamic psychiatry and straight medication management.

Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”
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I might not be the one providing therapy, but I might try to help the guy with some problem-solving, a discussion of his alcohol use, a little cognitive reframing, and at least make sure he's keeping his appointments with his therapist--get a release of information to share info, etc.
 
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The health care field is changing. Most Physicians are going to work for multispecialty groups or even hospitals. In that context, as a Psychiatrist, you are very likely to be doing mainly whatever is most efficient/whatever generates revenue.

However, you will likely be supervising mid levels like LCSWs and psychologists and will have to consult with PCPs as well as other specialists. Also you will do some therapy. But to think that psychotherapy will be done as it was 5 or 6 decades ago is not realistic, practical or good medicine.
 
Manicsleep said:
The health care field is changing. Most Physicians are going to work for multispecialty groups or even hospitals. In that context, as a Psychiatrist, you are very likely to be doing mainly whatever is most efficient/whatever generates revenue.

However, you will likely be supervising mid levels like LCSWs and psychologists and will have to consult with PCPs as well as other specialists. Also you will do some therapy. But to think that psychotherapy will be done as it was 5 or 6 decades ago is not realistic, practical or good medicine.
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Not this crap again. Psychologists are not mid-levels.
 
So nobody here is going to refute the picture portrayed in this article?

I found it frustrating that they only spent a few sentences on the psychiatrists who are still doing talk therapy. Still, this article gives me pause as a medical student considering this specialty.
 
LEdaddy said:
So nobody here is going to refute the picture portrayed in this article?

I found it frustrating that they only spent a few sentences on the psychiatrists who are still doing talk therapy. Still, this article gives me pause as a medical student considering this specialty.
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psychiatry: still with less poop than your chosen specialty. :D
 
I know a handful of psychiatrists who do primarily therapy - analysts or otherwise.

I think this field is what you make it. Doctors on average aren't very entrepreneurial, so take the jobs offered. No one offers you a job as a psychiatrist to be a therapist. You have to figure out how to make that happen on your own.
 
:D
LEdaddy said:
So nobody here is going to refute the picture portrayed in this article?

I found it frustrating that they only spent a few sentences on the psychiatrists who are still doing talk therapy. Still, this article gives me pause as a medical student considering this specialty.
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If you primarily want to become a psychiatrist in order to do talk therapy, it may not be worth your while to go through all of the medical rigamarole.

If you want to treat mental illness using an integrated, interdisciplinary, multimodal approach, then one very well-established path to that career is to enter medical school and go on to become a psychiatrist.

If you do the latter and then choose to be a full-time talk therapist, then yes, as this article describes, you WILL be in the minority of psychiatrists, and you may have to accept the reality that you will not be paid on par with other psychiatrists who choose to emphasize medical management (unless you become one of the rarer cash-only private practitioners of that art, limiting your self to those who can pay for your services without insurance assistance).

Again, as I said above, I found the article excessively polarizing in that it built on the dissatisfaction and ambivalence of one psychiatrist who, while preferring therapy, portrays himself as being "forced" into an extreme view of medication management that seems to preclude ANY therapeutic interaction with the patient. That is not a reflection of my practice style, nor of any of my close colleagues.

(I'm reminded of a recent Delta flight I was on. On approach to MSP, the late HQ of the former Northwest Airlines, the captain announced our arrival and slipped up and thanked us for flying Northwest. The lead flight attendant, a jovial Atlanta-based Indian male, picked up the PA and chuckled, "Those days are gone, Captain George." Take of this reminiscence what you will... :D )
 
LEdaddy said:
So nobody here is going to refute the picture portrayed in this article?

I found it frustrating that they only spent a few sentences on the psychiatrists who are still doing talk therapy. Still, this article gives me pause as a medical student considering this specialty.
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Plenty of residents in my cohort are doing psychotherapy. They are in private practice and largely do not accept insurance reimbursement.

-AT.
 
Here's a blog post written by a psychiatrist (who does a lot of psychotherapy) on the NY Times article: http://psychiatrist-blog.blogspot.com/2011/03/talk-doesnt-come-cheap.html

I'm a psychology student (Australian) but I also work in mental health research with psycologists and psychiatrists. At least one of the psychiatrists I work with mainly uses psychotherapy as a treatment modality (and is also heavily involved in research on psychotherapies).

It sounds like it's still doable, if somewhat rare.
 
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LEdaddy said:
So nobody here is going to refute the picture portrayed in this article?

I found it frustrating that they only spent a few sentences on the psychiatrists who are still doing talk therapy. Still, this article gives me pause as a medical student considering this specialty.
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These sorts of sentiments from med-students always puzzle me

"My primary interest is doing psychotherapy, but I heard psychiatrists don't do that much anymore so now I'm rethinking the field"

If your already a med-student and psychotherapy is your primary career interest then clearly psychiatry would be the most reasonable choice. Its not like your going to suddenly discover that radiologists have been picking up the slack in psychotherapy delivery.
 
psycscientist said:
Psychiatrists don't supervise psychologists (although I'm sure there are some that think they do). Nor are Ph.D. level individuals "mid-levels". Each degree has strengths and weaknesses, and frankly, one is not better than the other.
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Our Psychiatrists and PCPs supervise (explicitly/written into the contract) psychologists and social workers and send them patients based on their skill sets. I or another psychiatrist have a standing meeting with each one on a weekly basis to go over these patients and decide/approve the course of ongoing therapy. These are fully licensed psychologists and LCSW. We also supervise NPs and PAs.

It really depends on how you choose to practice. You can choose to bow to the system or make the system work for you. Psychologists and other therapists are in a tremendous oversupply and can be hired very easily for quite cheap. An enterprising Psychiatrist would do well to learn psychotherapy in its many forms so that they can then hire and supervise psychologists and LCSWs.
 
Not this again

The vast majority of doctorate level psychologists are not midlevelers. They are experts in whatever specific field they are in. Now, those who have a maters in psychopharm are absolutely midlevers, but they comprise a fairly small portion of all PhD/PysD psychologists.

Also, it does not matter who reports to who. That's administrative and has nothing to do with medical training. I used to shadow at a clinic run by the city that had a PhD psychologist as the immediate supervisor of the psychiatrists on staff. When I worked in the armed forces, I was in a hospital that had a nurse (RN!) as the second in command. That doesn't mean that the psychologist or nurse were above the physicians in terms of medical decisions. It just meant they pursued careers in administration and spent all their time...I don't know, doing whatever it is that administrative people do.

To the OP: The subject of psychiatrists doing talk therapy is discussed a lot in this forum so I would suggest to the OP that s/he look in the archive. Look at the beginning of the threads because these discussions deteriorate into 'psychiatrists vs. psychologists: who is better?' quite quickly
 
Manicsleep said:
It really depends on how you choose to practice. You can choose to bow to the system or make the system work for you. Psychologists and other therapists are in a tremendous oversupply and can be hired very easily for quite cheap. An enterprising Psychiatrist would do well to learn psychotherapy in its many forms so that they can then hire and supervise psychologists and LCSWs.
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...maybe if they are only doing therapy, but psychologists do more than just talk therapy, just like psychiatrists can do more than 15-min med checks for their entire day. Thankfully the other medical specialities have a greater appreciation for what psychologists can offer, as they have better things to do than try and belittle another profession. There is no shortage of neuro cases for me and other neuropsychologists, so you can carry on with your insecurities, and we'll actually contribute something to our patients and colleagues.
 
psycscientist said:
Psychiatrists don't supervise psychologists (although I'm sure there are some that think they do).
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Depends on where you work, no? At the two VA's I've worked at, psychiatrists run the patient care team and tasks are farmed out to nursing, social work, occupational therapy, and psychologists (testing and group therapy, from what I've seen).
psycscientist said:
Each degree has strengths and weaknesses, and frankly, one is not better than the other.
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Yep.
 
I can cite a number of instances where MDs were working under a psychologist (or any number of other PhD degrees...neuroscience, pharmacology, etc.) in a research setting. Does this mean as long as I'm in a research setting, I can refer to psychiatrists as mid-level scientists?;)

This comes up frequently and it always seems to be the same handful of folks. I'm learning not to take them seriously. Just speaks to the need to be picky about where (and who) you work with, and willing to laugh at the occasional "stereotype" you will run into that shows where the mostly undeserved reputations of physicians comes from. I've worked with quite a few, and have only met a few who thought of psychologists as "mid-levels". Interestingly, those were not psychiatrists and I suspect looked down on mental health as a whole....
 
Come on, y'all. Get over yourselves and move on.

-AT.
 
atsai3 said:
Come on, y'all. Get over yourselves and move on.

-AT.
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I know. lol but some people don't want to. i'm intrigued by the fact that psychologists even read this forum.

To OP, you CAN still do mostly therapy in many large cities. You can usually do a plurality of therapy with mostly medication. If you work in an academic setting you can also elect to do more therapy. But yes, the direction in which, IMHO, psychiatry is going, is away from therapy and joining the rest of the medicine and becoming more like a protocol driven, evidence based, procedurally oriented profession. To the extent that some psychiatrists want to be really good at therapy, the part of psychiatry oriented to therapy may split itself off into a separate field altogether.

Now I'm not saying this is a good thing. It may not be a good thing that in the era of managed care, MEDICINE in GENERAL is losing its personal touch, and psychiatry, though the most personal perhaps of all medical specialties, is sooner or later joining that inevitability. Nevertheless, even the most cynical can see some appeal in this. After all, what if I'm interested in from the get-go is to use mind-altering substances to help miserable people feel better, what profession affords me a better opportunity? One ought to conceive psychiatry as the medical specialty that deals primarily with some of the most intriguing pathologies of CNS. Psychiatry in the 21st century should be the quintessential BRAIN specialty.

This is slightly controversial, but I still think you should think of psychiatry vs psychotherapy as orthopedic surgery vs physical therapy. Many orthopedic surgeons know the principles of physical therapy, but they don't practice it for a variety of reasons, not the least of which is that it's not generally thought of as being "medicine". Somehow this is less acceptable in psychiatry. Does this make sense? Is this right? I'm not sure. Nevertheless, this is the way things are and this will be more and more the way things are going to become. Many psychiatrists, especially older ones, have taken it as a given that someone who does both meds and therapy yields a superior treatment than a fragmented treatment model. Is this really true? Is there randomized controlled study? What if I show through a randomized controlled study that fragmented care is not inferior to one provider care and is a lot cheaper? Would this persuade you? And what do we mean by non-inferior?

To generalize this, does spending more time with patients as doctors really improve patient care or does it just make patients more satisfied? I.e. does sitting in the first class section of an aircraft really improve on the efficacy of the flight? And what makes you think everyone DESERVES a seat in the first class? Not to be a contrarian, but the crux of many of these issues is precisely that fine line between what is the most OPTIMAL care and what is adequate and thus made efficiently universal.
 
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Sloux

I disagree. Plenty of evidence that what is most important is the therapeutic alliance. For alliance read satisfied. More time equals more satisfied or rather less time equals less satisfied. It matters not if you are prescribing only or just doing talking therapy. So the studies already exist no need to wonder hypothetically. Asking what is the nature of a good quality of service is another matter. You should not mix those two things up.

There is never an excuse for providing suboptimal care to anyone on a personal level. To say I must treat one patient in a suboptimal way for the benefit of the rest of my other patients is absurd.

Why in your first question "After all, what if I'm interested in from the get-go is to use mind-altering substances to help miserable people feel better, what profession affords me a better opportunity?" do you put the technique before the outcome?

Regarding psychiatry vs psychology contrast two bald men fighting over a comb. In the 1950 the APA was dead against anyone other than a psychiatrist providing talking therapy. It's hard not to see all this guff as anything other than professional protectionism at best.
 
I'm one of those odd freaks who thinks that the mind is a fundamentally brain phenomenon. And that psychotherapy is therefore a biological intervention. Someone made the comparison btwn Ortho and PT. Funny thing, PT is a 'biological' intervention. More importantly, it's a hell of a lot more complex than ortho. At least, if you're any good at it.

The human body is a fundamentally adaptable organism, and much of the pathology that the average person is prey to (whether it be DM2, MDD, OA, GAD, or CHD) is the result of biological adaptation taking place on a genetic and developmental substrate.

I see psychopharm as quite equivalent to ortho in its failure to appreciate the richness of adaptation and historicity (i.e. dependence on the passage of time) in defining our phenotype both in health and disease. One of the reasons I'm a big fan of positive psych as well as exercise phys. I also believe that this narrow view which restricts our temporal understanding of health and disease to the here and now leads to poor health and poorer outcomes.

MDD, DM2, OA, or any of a host of chronic diseases is not a 'here and now' state but rather the result of chronic (mal)adaptation. It only makes sense to apply interventions that are temporally-dependent and adaptation-focused in the pursuit of health and improvement of the disease state.

That's basically a bunch of gobbledygook saying that psychotherapy is a biologically-valid and arguably epistemologically more sound approach than pure psychopharm. Now, I certainly believe in the importance of psychopharm (all pharm) in improving health but only in the context of also improving the adaptive component of the phenotype.

Again, I look at psychotherapy as a fundamentally biological phenomenon, and I think this improves my ability to use other adaptive biological approaches to patients. The anxiety d/o patient with high sympathetic reactivity and HTN responds very well to an exercise regimen aimed at lowering basal sympathetic tone both somatically and psychiatrically. Being able to add psychotherapy to the mix improves not only the anxiety but also their adherence to the exercise regimen. The MDD patient with OA as a result of chronic muscle imbalances ends up coming off of their motivation-robbing opiates, improves their functional status, and decreases their pain when I address those chronic muscle imbalances. Pretty sure that facilitates the treatement of their MDD.

Ok, I'm off message now. Point is, psychotherapy addresses the process of adaptation that is a central biological phenomenon in a wide range of psychopathologies. It thus should remain a part of the psychiatrists arsenal.
 
same21 said:
http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?pagewanted=4&ref=us

I hope to become a psychiatrist who uses talk therapy as well as medication. This this article correct in that talk therapy is no longer a part of psychiatry? Id love to hear some personal experiences
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It's more nuanced than the article portrayed it.

Many people, especially in cities, do 45-minute talk therapy sessions along with meds. Some, such as people who were trained in analysis along with straight psychiatry, will do only 45-minute sessions. In my experience, many more do a mixture -- ex, in 10 hours, they might see 6 talk therapy patients (6 hours) plus 4 hours of 15-30 minute med checks.

If it is just med checks, the goal can be for the person to see a psychologist or LCSW or NP for therapy, or the person may simply want to stay on their meds and not talk. Take a parent with two kids who had an episode of depression and is now much better on zoloft 75mg. Do you think they want/need to talk for an hour a week, or have the time to do so? They could be just fine with med checks and simple supportive therapy. This is consistent with the fact that a large percentage of all antidepressants prescribed (the majority?) are by PCPs who certainly don't do long sessions of talk therapy.
 
Therapist4Chnge said:
...maybe if they are only doing therapy, but psychologists do more than just talk therapy, just like psychiatrists can do more than 15-min med checks for their entire day. Thankfully the other medical specialities have a greater appreciation for what psychologists can offer, as they have better things to do than try and belittle another profession. There is no shortage of neuro cases for me and other neuropsychologists, so you can carry on with your insecurities, and we'll actually contribute something to our patients and colleagues.
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Neuro cases? This is not a thread about neuro cases. It's about talk therapy and its relevance to psychiatry today. Go do your neuro cases under a neurologist's supervision. You make ad hominem attacks, say you ACTUALLY CONTRIBUTE and am hurting you by belittling you...and I am the one thats insecure...

The point here is that psychiatrists need to learn psychotherapy as well as psychometrics to be able to supervise and do those things. It is also an ACGME requirement.

I can cite a number of instances where MDs were working under a psychologist (or any number of other PhD degrees...neuroscience, pharmacology, etc.) in a research setting. Does this mean as long as I'm in a research setting, I can refer to psychiatrists as mid-level scientists?;)
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Works for me. The PI of the lab (or research team) is the head honcho. They supervise everyone else. When I was doing research, even though I ran my own clinic, I certainly was being supervised even though I worked independently.
 
Agree with the above posts.

But I just wanted to mention that I got a letter from United Health Care telling me they will not cover for psychotherapy and only wanted me to do medication management.

Anyone get such a letter that takes patients from UHC?
 
whopper said:
Agree with the above posts.

But I just wanted to mention that I got a letter from United Health Care telling me they will not cover for psychotherapy and only wanted me to do medication management.

Anyone get such a letter that takes patients from UHC?
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But aren't you glad that you're dealing with the free-market private sector , and not some bureaucratic government-controlled health care program? :rolleyes:
 
masterofmonkeys said:
Ok, I'm off message now. Point is, psychotherapy addresses the process of adaptation that is a central biological phenomenon in a wide range of psychopathologies. It thus should remain a part of the psychiatrists arsenal.
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The first sentence doesn't logically lead to the second sentence. I'm not disputing the fact that therapy isn't biologic or that it isn't effective. I'm very well aware that both are true. This isn't the issue. The issue is, suppose I can show via controlled trials that split psychologist/psychiatrist format is equally effective and lower costing as psychiatrist only format for med+therapy, wouldn't I be then compelled to recommend this as what the insurance should pay for? And if it comes to a point where psychiatrists no longer practice psychotherapy, why should they be forced to learn it? It's a question about division of labor and healthcare policy, not a question about efficacy or mechanism of therapy.

Also, let me be clearer and perhaps a bit more provocative. If psychiatrists are paid as much for therapy as for meds, psychotherapists will have even LESS job prospect than they do now. I'm not exactly sure what they are arguing for. If you take the psychologists argument at face value, psychologists are BETTER at therapy than psychiatrists. Wouldn't this make an argument that psychiatrists should lay off doing therapy altogether? The logic in this "debate" is completely unclear to me.

The whole thing hinges on this contradictory fact that there's no evidence that psychiatrists do better therapy, but patients, especially rich patients, prefer MDs to do their therapy regardless. While I applaud some (ibid's) wishing for "optimal" treatment for ALL, I cannot in good faith justify paying (as a tax payer or an insurance beneficiary) for something quite a bit more expensive for equivalent efficacy. I truly believe that psychiatrist therapy today, in light of abundant non MD therapy provider, is akin to 1st class flying or private pre-k.
 
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But aren't you glad that you're dealing with the free-market private sector , and not some bureaucratic government-controlled health care program? :rolleyes:
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Just go to another insurance. Show your patients the letter and tell them that you prefer to do therapy as well. Or hire a therapist if you have enough patients and refer out to them keeping part of the proceeds (you can hire them part time...its actually better this way.)
 
Chimed said:
Do you think it wold be any different in regards to paying psychiatrists for psychotherapy?
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No--just wishing Sarah Palin and Michelle Bachmann and their friends would have to deal with some of the prior authorizations and other bureaucratic crap that that particular for-profit bureaucracy has foisted upon us this week...
 
Getting somewhat OT, and I'll stop it with this post (anyone want to talk about this subject more, make a new thread).

Regarding insurance companies, Anthem has lowered their reimbursement to psychiatrists and as a result, hardly any psychiatrist in my area still covers them. UHC, already mentioned above. Humana will only cover a psychiatrist if you work in a hospital or case manager affiliated that in effect pretty much kills any possibility Humana will pay for my services but despite that I still got Humana patients coming to me. They're upset, but they still come and pay out of pocket. At least Humana will cover their meds.

As mentioned in other threads, the office has to spend a lot of energy getting insurance companies to pay for things. It's a game, and I don't recommend that the doctor do this becuase it's not cost effective and will drive you nuts. You'll have to have an office manager.

As for the patients, its not like they know this. When people get an insurance policy, it's like reading a phone book as to what they will or will not cover, and many don't have any conditions when they sign up for it. To actually read the manual is almost pointless unless you're expecting a specific type of disorder to happen.

All-in-all I still have found it very profitable to work in private practice. I do work in an office where several can offer psychotherapy, so in the case of UHC patients, I can at least refer them to someone else for that, but it really does take a heck of a lot out of the quality of the interview. When I talk to patients, I just don't want them to do a rating scale, mention side effects, then I adjust a dosage.

The only major advantage I've seen with insurance companies, and this is not by design to help the patient, is of the patients I got on Suboxone, many insurance companies will only pay for the medication for a limited amount of time, giving the patient an incentive of financial fear to do what they can to get off of it while they can get services covered. I don't mind patients being on it for some time, but there are some that once comfortable on it don't want to get off and it raises suspicion (that is not provable) that they're selling it.
 
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masterofmonkeys said:
I'm one of those odd freaks who thinks that the mind is a fundamentally brain phenomenon. And that psychotherapy is therefore a biological intervention. Someone made the comparison btwn Ortho and PT. Funny thing, PT is a 'biological' intervention. More importantly, it's a hell of a lot more complex than ortho. At least, if you're any good at it.

Ok, I'm off message now. Point is, psychotherapy addresses the process of adaptation that is a central biological phenomenon in a wide range of psychopathologies. It thus should remain a part of the psychiatrists arsenal.
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Nice post. :thumbup: The evidence from fMRI is supporting the biological correlates that psychotherapy is changing neural networks. Very interesting stuff.

Although I agree that there can be little doubt "mind" is heavily correlated to biological activity, I think the jury is still out on whether or not we can explain ALL mental phenomena by purely from neurological mechanisms. We are so far away from explaining consciousness that I think we need to keep open minded...But that is WAY off topic... ;)
 
sluox said:
The issue is, suppose I can show via controlled trials that split psychologist/psychiatrist format is equally effective and lower costing as psychiatrist only format for med+therapy, wouldn't I be then compelled to recommend this as what the insurance should pay for?
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You raise some good questions that I'm sure a lot of insurance companies and practice management folks would also like to know.

Regarding a psychiatrist/therapist split, in my limited experience, I have found this to be a good model from a patient care perspective for many patients. I think it is very useful to have 2 "eyes" on a patient and being able to get 2 different perspectives on a patient's issues, pathology, and strengths. The key is whether or not the providers are in communication.

Also, although I can't produce the study, I believe I've read some reports that a split psychiatrist/therapist model is more cost effective.

sluox said:
And if it comes to a point where psychiatrists no longer practice psychotherapy, why should they be forced to learn it? It's a question about division of labor and healthcare policy, not a question about efficacy or mechanism of therapy.
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Because learning therapy will make us better psychiatrists whether or not you "do therapy" or not. Any time you have a patient in a room and are talking about triggers for depression, anxiety, or whatever, you can always use therapeutic techniques here and there. I am always pulling out stuff I know from CBT and other therapy techniques during medication management. If you get into dynamic issues, then there are all kinds of things to consider about the doctor-patient relationship from the moment the patient walks into the room to the time you are signing the script. Having training in psychodynamics will help a psychiatrist be aware of those issues and help him or her be able to appreciate nuances with the patient that could otherwise be missed. The idea that a psychiatrist like the one in the NY Times article would tell a patient something to the effect of, "You need to tell your therapist about that because I'm just adjusting meds" is bad patient care on so many levels...

I just think my therapy training makes me a better overall psychiatrists and better psychopharmacologist whether or not I'm formally doing therapy with a patient or not. No matter what happens to the future of psychiatrists using therapy, I think it would be tragic to cut that from our training.
 
OldPsychDoc said:
No--just wishing Sarah Palin and Michelle Bachmann and their friends would have to deal with some of the prior authorizations and other bureaucratic crap that that particular for-profit bureaucracy has foisted upon us this week...
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I'm just wishing that Sarah Palin runs for president so we can have some good SNL skits for the next year. :D
 
sluox said:
The whole thing hinges on this contradictory fact that there's no evidence that psychiatrists do better therapy, but patients, especially rich patients, prefer MDs to do their therapy regardless. While I applaud some (ibid's) wishing for "optimal" treatment for ALL, I cannot in good faith justify paying (as a tax payer or an insurance beneficiary) for something quite a bit more expensive for equivalent efficacy. I truly believe that psychiatrist therapy today, in light of abundant non MD therapy provider, is akin to 1st class flying or private pre-k.
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Chimed said:
You raise some good questions that I'm sure a lot of insurance companies and practice management folks would also like to know.

Regarding a psychiatrist/therapist split, in my limited experience, I have found this to be a good model from a patient care perspective for many patients. I think it is very useful to have 2 "eyes" on a patient and being able to get 2 different perspectives on a patient's issues, pathology, and strengths. The key is whether or not the providers are in communication.

Also, although I can't produce the study, I believe I've read some reports that a split psychiatrist/therapist model is more cost effective.



Because learning therapy will make us better psychiatrists whether or not you "do therapy" or not. Any time you have a patient in a room and are talking about triggers for depression, anxiety, or whatever, you can always use therapeutic techniques here and there. I am always pulling out stuff I know from CBT and other therapy techniques during medication management. If you get into dynamic issues, then there are all kinds of things to consider about the doctor-patient relationship from the moment the patient walks into the room to the time you are signing the script.
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The reality is that this dicotomy between psychiatrist and psychologist as the best provider is a false one in many cases. They are not the only actors on the stage.

Take the case of the person with a personality disorder, it requires that a much wider team needs to be skilled to some extent and familiar with the principles of DBT. Starting with ER/A&E staff through to ward staff be they nurses, health care assistants, OTs or advocacy workers.

With out this whole system appoach it is no wonder that wards fill up with people who don't need to be admitted and when they are admitted they run rings around staff and induce even skilled staff (including psychiatrists) into a game of prove me wrong. (which they enjoy even when staff think the are "winning"). This battle of wills makes wards the toxic non-threaputic places everyone knows they really are.

In that context (the real context) the question about who should pay and who should provide changes to what should the whole service should look like and what training everyone should have. Sadly they way services look are not defined by what works but how they are paid for. And I stress how they are paid for not what is cost effective.
 
Also, although I can't produce the study, I believe I've read some reports that a split psychiatrist/therapist model is more cost effective.
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I agree with chimed on the need for therapy in our training as psychiatrists. It's beneficial even for those not practicing therapy without meds. Therapeutic dynamics occur all the time, in every doctor-patient interaction.

On the other issue, just because psychologists get more in their baseline training doesn't indicate a superiority of split care and division of labor.

To answer the split care cost question, I did a little lit search (it's how I burn my non-existent free time). In a pubmed search examining keywords of "psychotherapy, cost effectiveness," I got over 1300 hits. Amazingly I only found 1 article which explored this question directly, and it was from 1999!
Here: http://www.ncbi.nlm.nih.gov/pubmed/9989575
Finding - Brief therapy by a social worker was the cheapest if no meds are needed, but if combo therapy is indicated, getting everything from a psychiatrist was the least costly.

I did a psycinfo search as well, with 213 hits, but none that were any different.

Regarding the changing role of psychologists, I found this article also interesting, giving a historical perspective on changes in roles since WWII, when psychologists began training in therapy.
http://www.ncbi.nlm.nih.gov/pubmed/8881525
 
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Great links nitemagi.

LCSWs, MFTs etc are already dominating the scene in the therapy world and doing so at a much lower cost. They are as good as any other type of therapist and in many cases the best therapists around.
 
Manicsleep said:
Great links nitemagi.

LCSWs, MFTs etc are already dominating the scene in the therapy world and doing so at a much lower cost. They are as good as any other type of therapist and in many cases the best therapists around.
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I've always argued that the best in terms of cost effectiveness with good patient care is a combination of psychiatrist/LCSWs. But I've been fortunate to work in a training institution with an excellent LCSW program, so I might be biased in regards to quality.

In our clinic:
Psychiatrists/Fellows/Resident: Do all medication management and some therapy. They are also involved in research both as PI's and co-PI's.
Psychologist (including post-docs): Do therapy, but are heavily involved in teaching and research.
LCSWs: Do the bulk of clinical therapy.
 
I am sure that you can find top level psychotherapists in all professions; psychiatrists, psychologists, LCSWs and on down the line. If I won the lottery and wanted psychotherapy, I would probably choose an analytically trained psychiatrist. However, in my experience LCSWs are the most consistent and give the most bang for the buck.
 
sluox said:
I know. lol but some people don't want to. i'm intrigued by the fact that psychologists even read this forum.
Click to expand...

As a psychologist on faculty in a psychiatry department, I happily read this forum. Career development issues in psychiatry are relevant to my work, and I directly supervise and train med students and psychiatry residents. I also conduct my own independent research, and see psychotherapy patients under my own independent license that by no means stipulates that I be supervised by any MD colleague. I respect and value my psychiatry colleagues, and as far as I can tell, the feeling is mutual.
 
LM02 said:
As a psychologist on faculty in a psychiatry department, I happily read this forum. Career development issues in psychiatry are relevant to my work, and I directly supervise and train med students and psychiatry residents. I also conduct my own independent research, and see psychotherapy patients under my own independent license that by no means stipulates that I be supervised by any MD colleague. I respect and value my psychiatry colleagues, and as far as I can tell, the feeling is mutual.
Click to expand...

Absolutely! :thumbup: Many of my favorite and best teachers are psychologists. They are highly and well respected where I train.
 
I would like to suggest the following definition.

Mid-level: a healthcare practitioner who is not licensed as an independent practitioner. One who is required by laws/regulations to have patients referred by another healthcare practitioner for a particular type of care, or that on-going care be reviewed and/or authorized by another healthcare practitioner. A Mid-level provider cannot lawfully acquire, diagnoses, treat, and discharge all of his patients without some form of consultation/supervision.

Examples:
Physical therapists cannot, as far as I know, see new patients without those patients being referred by a physician for treatment of a specific condition, usually with specific goals.

Physician assistants cannot treat patients independently. They are required to have their diagnoses and treatments reviewed/approved at some point.

As far as I know, the situation for Nurse Practitioners varies by state, but most states have some form of supervision that is required - though sometimes only a percentage of cases.



Psychologists and therapists do NOT generally fall under this definition of "Mid-level," since they are permitted by law to independently acquire, diagnose, treat, discharge patients from their care - without EVER discussing ANY case with any other practitioner. While some such professionals may choose to practice in settings where supervision is required, or practice certain modalities that require supervision (psychopharmacology), that situation is not inherent to the title. If there are some psychologists or therapists who do not pursue full independent licensure (some psychologists stop at a level that does require referral from another practitioner or supervision by another practitioner), that does NOT define the title of "Psychologist" as Mid-Level.

Does that help the discussion, or does it just lead to more questions and more squabbling over semantics?
 
kugel said:
I would like to suggest the following definition.

Mid-level: a healthcare practitioner who is not licensed as an independent practitioner. One who is required by laws/regulations to have patients referred by another healthcare practitioner for a particular type of care, or that on-going care be reviewed and/or authorized by another healthcare practitioner. A Mid-level provider cannot lawfully acquire, diagnoses, treat, and discharge all of his patients without some form of consultation/supervision.

Examples:
Physical therapists cannot, as far as I know, see new patients without those patients being referred by a physician for treatment of a specific condition, usually with specific goals.

Physician assistants cannot treat patients independently. They are required to have their diagnoses and treatments reviewed/approved at some point.

As far as I know, the situation for Nurse Practitioners varies by state, but most states have some form of supervision that is required - though sometimes only a percentage of cases.



Psychologists and therapists do NOT generally fall under this definition of "Mid-level," since they are permitted by law to independently acquire, diagnose, treat, discharge patients from their care - without EVER discussing ANY case with any other practitioner. While some such professionals may choose to practice in settings where supervision is required, or practice certain modalities that require supervision (psychopharmacology), that situation is not inherent to the title. If there are some psychologists or therapists who do not pursue full independent licensure (some psychologists stop at a level that does require referral from another practitioner or supervision by another practitioner), that does NOT define the title of "Psychologist" as Mid-Level.

Does that help the discussion, or does it just lead to more questions and more squabbling over semantics?
Click to expand...

When it comes to my experience with PCP MD's and PT, the referral was "Diagnose and Treat"

That being said, the PT's associated with student health are the same ones taking care of our athletes so I assume they are quite good and the doctors know that.

*But this is irrelevant to conversation, just thought it was amusing when I read the doctors note.
 
Last edited:
Well, consider where you work and your contract.

I work on an inpatient unit. We got psychologists, social workers, music therapists up here but none of them can do anything without going through me. I hate it.

They arent checking with me every second or anything but we have a treatment team every week. The hospital lawyers have told another psychiatrist on a suicide case that he was responsible for the therapist and was his supervisor.

So its not that simple. Supervision is supervision and sometimes you may not like doing it because you have a rogue music therapist who needs some risperdal.
 
I would like to suggest the following definition.

Mid-level: a healthcare practitioner who is not licensed as an independent practitioner. One who is required by laws/regulations to have patients referred by another healthcare practitioner for a particular type of care, or that on-going care be reviewed and/or authorized by another healthcare practitioner. A Mid-level provider cannot lawfully acquire, diagnoses, treat, and discharge all of his patients without some form of consultation/supervision.
Click to expand...

A psychologist in an inpatient setting or in my practice could meet those requirements right?
 
surftheiop said:
These sorts of sentiments from med-students always puzzle me

"My primary interest is doing psychotherapy, but I heard psychiatrists don't do that much anymore so now I'm rethinking the field"

If your already a med-student and psychotherapy is your primary career interest then clearly psychiatry would be the most reasonable choice. Its not like your going to suddenly discover that radiologists have been picking up the slack in psychotherapy delivery.
Click to expand...

Because most of us envision ourselves probing the depths of a person's soul to offer them enduring solutions, not running through SIGECAPS, ruling out past manic episodes, and then writing an SSRI. When confronted with the thought of mostly running through a simple questionnaire style interaction and then choosing an appropriate medication comes up it makes us feel that there is nothing special about psychiatry after all; that in fact it may have left behind the human element that drew us to the field in the first place. Remembering that another field had something compelling to it (and feeling like Psych has lost its allure) we just might choose that other field, not because we will get to do talk therapy there but because if we can't have that kind of interaction at all we might as well choose something else to pursue.

Not to be offensive, but diagnoses by DSM criteria don't seem to be that hard to make for a large proportion of psych patients and you can look up standard of practice treatments from any computer. If we are only prescribing medications and watching for side effect is that really a satisfying and rewarding professional life, especially given the immense investment in training we have undergone? Just a devil's advocate question, but in my darker moments I sometimes feel this way.
 
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