Challenges
At a recent seminar I was asked to tell psychiatry residents why they needed to learn how to do psychotherapy. The question is symptomatic of our times. My answer was a variation on Glen Gabbard’s classic words: "Psychotherapeutic skills are needed in every context in psychiatry because the same phenomena that emerge in psychotherapy—transference, resistance, countertransference, schema, automatic thoughts—appear in other contexts."[1]
Unfortunately, the number of psychiatry residents being taught to think that way is diminishing. Once upon a time during a clinical clerkship at UCLA, I observed psychiatric residents learning from tenured faculty how to take in-depth psychodynamic histories that would facilitate successful psychotherapeutic outcomes. After joining the department a few years later I saw those faculty members systematically replaced by biologically-oriented researchers, few of whom were knowledgable about verbal therapies and some of whom proudly declared their bailiwicks to be "psychotherapy-free zones."
Departments like ours have made many valuable scientific contributions, but the teaching of interpersonal skills has had to be almost fully outsourced to clinicians in private practice. PCFA is the Semel Institute's primary resource for resident psychotherapy supervision and the educational experience of personal psychotherapy. Thanks to excellent departmental leadership we are valued and supported in pursuit of these purposes. Nonetheless, there is a certain in-house culture all too common in psychiatric training centers that looks with derision at what we define as balanced clinical training.[2] One manifestation of that culture is an erroneous bias that the evidence base supporting psychotherapy is less trustworthy than the one supporting psychopharmacology. Another is the belief shared with insurance companies that the practice of psychotherapy is best left to non-prescribers.
PCFA has consistently opposed that culture. In an anonymous poll taken at their 2015 Spring Retreat, 68% of the residents attending (n=38) said that they needed more psychotherapy training. At our monthly Directors' meetings, we regularly discuss ways to support that need. In promoting psychotherapy education our mission is not to diminish psychopharmacology. I have been a psychopharmacologist as well as a psychotherapist for over 40 years. I am certain that that my value as a psychiatrist is based on being trained in both. As New York Times contributing psychiatrist Richard Friedman puts it: "Sure, as a psychiatrist, I can quell a patient’s anxiety, improve mood and clear psychosis with the right medication. But there is no pill — and probably never will be — for any number of painful and disruptive emotional problems we are heir to...."[3]
Not everyone on the clinical faculty agrees. One of our Directors has criticized the PCFA Executive Committee for talking too much about psychotherapy. He is a former UCLA resident who still identifies with the in-house culture. Will PCFA someday be dominated by those like him? Hopefully not. Many of his peers on the Executive Committee have avoided or escaped that culture. Dr. Joshua Pretsky, past-president of PCFA, has given masterful case seminars on psychodynamic psychotherapy to the residents in recent years. Drs. Shirah Vollmer, David Sones, John Z. Little, Robert Ashley, and Elizabeth Casalegno -- all former UCLA psychiatry residents -- have been among PCFA's strongest voices on behalf of psychotherapy.
Dare those of us who are a bit older hope that those like Josh, Shirah, Dave, Zeb, Rob and Elizabeth will transmit the complex wisdom of our profession to future generations? If that happens, we can dream more optimistically of a future in which well-trained psychiatrists will be taken off the endangered species list.
Adaptations
One of the greatest dangers to becoming a good psychiatrist is the financial incentive to spend as little time with patients as possible. In his thought-provoking book Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis, Dr. Daniel Carlat tells us that at standard reimbursement rates he earns a net income of $130 per hour for doing multiple "med checks" compared with only $70 per hour for a single psychotherapy session.[4] Those figures suggest that in forty years a psychiatrist might earn millions of dollars more by handing out prescriptions rather than practicing psychotherapy. Is it any wonder that a diminishing number of psychiatrists (fewer than one out of ten) are full-time psychotherapists? [5]
How could anyone justify giving up so much income? The answer is that one doesn't have to. Speaking from personal experience, I can confirm that there is a way to earn the same amount as most psychiatrists while doing far more than the average amount of psychotherapy. This kind of practice offers the satisfactions of spending as much time with patients as their condition requires, having significant therapeutic relationships, avoiding the boredom of writing the same prescriptions day in and day out for relative strangers, and feeling that one’s work is calling upon the best of one’s abilities.
How can this be done? — The answer is to see people for forty-five minutes (“full sessions") during their initial visits and then schedule:
(a) continuing full sessions for psychotherapy alone or psychotherapy plus medication management as frequently as necessary, or
(b) fifteen minute medication checks typically tapering off to once every three months.
This method of scheduling allows for interweaving both psychotherapy and medication management visits throughout the day with fifteen minute breaks in between.
Why doesn’t this dilute income? Fees can be charged on an income-based sliding scale. In my practice (I'm semi-retired now) it ran from pro bono to full fee (substantially more than insurance would reimburse). By using that approach, one could work outside the constraints of managed care/third party restrictions. Most importantly, fees could be charged according to the time allocated, not the service provided. I charged the same amount for each fifteen minute time segment whether combined in forty-five minutes of verbal therapy or used singly in medication management. That completely eliminated any financial difference between pharmacotherapy and psychotherapy. If more psychiatrists were to set their own fees rather than allowing insurance companies to shape their behavior, patients would receive better care. It takes courage for practitioners to swim against the tide of external control that has inundated our health care system, but in psychiatry it can still be done. All it takes is determination to practice according to the highest standards, which means spending as much time with patients as their condition requires using all the tools at one’s disposal. Every psychiatric resident owes it to himself or herself to learn as much as possible about psychotherapy, psychopharmacology and all the other scientifically-validated treatments and then to practice in a way that offers patients the best interventions for their particular problem in the context of a caring and comprehensive therapeutic relationship. The reputation that follows from this kind of practice draws patients whose ability to pay full fee keeps the good psychiatrist’s income comparable to those who receive more for doing less.
Psychiatric residency training programs need to include models such as I have just described in their curriculum. Instead, the residents see patients for pharmacological management in the Medication Clinic who are typically billed substantially more than patients they treat psychotherapeutically in RPC ( the Resident Psychotherapy Clinic). This disparity devalues psychotherapy for both the trainee and the patient. In the odd case where a resident has been assigned the same patient in both clinics, we have the perfect storm for disparaging the time spent in psychotherapy - not to mention creating a bizarre split in patient care (“We’ll discuss drug side-effects on Monday, and your other feelings on Thursday.")
We must do everything to avoid letting the economic pressures on psychiatric training programs and the systems in which they exist trickle down onto residents in ways that predispose them to make career choices that are financially-driven. This process inevitably works to the detriment of patients, psychiatric professionalism and the health of society. Teaching residents how to succeed by doing the right thing is the best way to enlist them in the battle to save good psychiatrists from extinction.
[1] Gabbard GO (2009) Deconstructing the “med check.” Psychiatric Times.
[2] Metzner RJ (1999) Throwing Away the PITS. Southern California Psychiatrist.
[3] Friedman RA (2015) Psychiatry's Identity Crisis. New York Times.
[4] Carlat D (2010) Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis. Free Press, New York.
[5] Mojtabai R, Olfson M (2008) National trends in psychotherapy by office-based psychiatrists. Archives of General Psychiatry 65:962-970.
(This post was updated on 4/22/18)