03 Jun The Psychiatrist as Psychotherapist: Contemplations on a Species at Risk of Extinction

Posted at 3:40 pm in Individual Therapy by jlbworks

By Philip Chanin, Ed.D, ABPP, CGP
Board Certified Clinical Psychologist
Assistant Clinical Professor, Department of Psychiatry
Vanderbilt University Medical Center

For Psychiatrists Who Take Insurance, Talk Therapy Doesn’t Pay

“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.’ Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy…Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.” (“Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy,” by Gardiner Harris, The New York Times, March 5, 2011)

Recently I searched for and found this article, which is as poignant for me today as it was when I first read it eight years ago. It is abundantly clear that Dr. Levin had been trained in and loved doing psychotherapy, and that the choice he has made, for financial reasons, to stop doing psychotherapy and do only medication management has left him feeling often empty. “I had to train myself not to get too interested in their problems,” he said, “and not to get side-tracked trying to be a semi-therapist.” The article goes on to state, “A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since.”

“Now, like many of his peers,” the article says, “Dr. Levin treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.”

Dr. Levin goes on to say “that the quality of treatment he offers is poorer now than when he was younger. For instance, he was trained to adopt an unhurried analytic calm during treatment sessions. ‘But my office is like a bus station now,’ he says. ‘How can I have an analytic calm?’” The article continues, saying “…the brevity of his appointments—like those of all of his patients—leaves him unfulfilled. ‘I miss the mystery and intrigue of psychotherapy,’ Dr. Levin states. ‘Now I feel like a good Volkswagen mechanic. I’m good at it, but there’s not a lot to master in medications.’”

“At first, all of us held steadfast, saying we spent years learning the craft of psychotherapy and weren’t relinquishing it because of parsimonious policies by managed care,” Dr. Levin laments. “But one by one, we accepted that the craft was no longer economically viable…It took me at least five years to emotionally accept that I was never going back to doing what I did before and what I loved.”

The Decline in Psychotherapy Training in Psychiatry

Some statistics bear out the dramatic decline in recent years in most psychiatrists’ interest in psychotherapy. The American Academy of Psychotherapists (AAP) is a preeminent national interdisciplinary psychotherapy organization, and it has played a powerful role in my own development as a psychotherapist for the past 27 years. It has 309 members. Only 10 are psychiatrists or other physicians. The Nashville Psychotherapy Institute (NPI) has played a parallel role for me here and has been vital in my building a personal and professional network during this same period of time. NPI has 314 active members. Only 4 are psychiatrists.

Google lists 295 Nashville psychiatrists. The psychiatrists here who are best known to continue to schedule 45-minute sessions for talk therapy are psychoanalysts who have been through their own personal psychanalysis and have trained for 4 years at the St. Louis Psychoanalytic Institute. These include Doctors Tom Campbell, Anne Bartek, Bill Kenner, Hal Schofield, and Sarah Aylor. Other non-analysts who are known to me to see all their patients for extensive evaluations and for 45-minute follow-up sessions for a combination of talk therapy and medication management include Doctors Mike Reed, Scott West, Casey Arney, John Lambert, Scot McKay, Jack Koch, Daniel Barton, Jill Debona, and Ira Phillips. I am sure there are others not known to me personally, though I think it unlikely that the number would reach the 11% figure (of 295 Nashville psychiatrists) that is mentioned in the above article.

For the past 10 years, I have seen Vanderbilt psychiatric residents for psychotherapy and supervision, and for the past 6 years in weekly psychotherapy process groups. Thus, I have witnessed firsthand the degree to which training in psychotherapy is devalued in relation to the amount of training devoted to medication management and biological psychiatry. Residents do not even see their first psychotherapy patient until the beginning of their 3rd and next to last year of residency! Residents are not required to undergo psychotherapy and are given no time out of their busy schedule to do so. Thus, one recent resident who wanted to get psychotherapy spent a month trying to find a Nashville psychotherapist who had Saturday hours.

It was not always like this in Vanderbilt’s Department of Psychiatry. For 3 decades, psychoanalyst Volney Gay, Ph.D., was a powerful voice for the training of psychiatric residents in psychodynamic psychotherapy. Other psychoanalysts, such as Doctors Anne Bartek and Tom Cambell, played major roles in providing and advocating for psychotherapy training.

Psychiatrist Dr. Mike Reed, who trained in the Department 30 years ago, wrote to me this week: “I was lucky enough to have had as my mentors Marc Hollender, Pietro Castelnuovo-Tedesco, James Nash, and most importantly, Volney Gay. I felt well trained in psychotherapy and focused on getting as much training as I could during my years at Vanderbilt. But, I think the average graduating resident now may have had much less exposure and probably is inadequately trained. Or perhaps it’s a lack of interest, which is hard to comprehend. Maybe though the current emerging flock of psychiatrists think of providing psychotherapy as ‘old school.’”

Even in the past, however, personal psychotherapy was not required of the residents. Instead, most underwent euphemistically defined “self-awareness” sessions for 6 months with Dr. Campbell or another member of the resident or volunteer faculty. The “self-awareness” program dried up about 3-4 years ago when Dr. Gay’s contract with the Department ended. Last year, Doctors Campbell and Bartek taught their last psychotherapy class to the residents. Dr. Gay also retired from Vanderbilt last year and Dr. Bartek gave up her role in promoting psychotherapy in the Department.

No one has stepped into the void that their departure has created in the training of Vanderbilt psychiatric residents in psychodynamic psychotherapy. These days, most of the psychotherapy training in the Department focuses on CBT and DBT rather than psychodynamic psychotherapy. 3rd and 4th year residents carry a caseload of 5 or so patients with one psychotherapy supervisor. The Department does support a 1-hour weekly process group where residents can together air their professional and personal challenges. But most current psychiatric residents have minimal interest in practicing psychotherapy once they graduate. Most plan careers in such areas as inpatient or geriatric or forensic psychiatry. They are very well trained for these endeavors, but unfortunately not as psychotherapists.

As a Nashville psychoanalyst wrote to me recently, “Big Pharma and the insurance companies have gutted psychiatry at this point. As an analyst, I feel at times like a Buddhist monk in his saffron robes, with my bowl, asking for rice, working for lower fees, or being restricted to seeing only the financially privileged.”

The above cited article about Dr. Levin includes a profile of one of his former colleagues, Dr. Louisa Lance, who, “practices the old style of psychiatry from an office next to her house…She sees new patients for 90 minutes and schedules follow-up appointments for 45 minutes. Everyone gets talk therapy. Cutting ties with insurers was frightening, since it meant relying solely on word-of-mouth, rather than referrals within insurers’ networks,” Dr. Lance stated, “but she cannot imagine seeing patients for just 15 minutes. She charges $200 for most appointments and treats fewer patients in a week than Dr. Levin treats in a day. ‘Medication is important,’ she said, ‘but it’s the relationship that gets people better.’”