Wednesday, July 05, 2006

The Psychiatrist as Therapist


[by dinah]

I started this discussion when I agreed with Shiny Happy Person and her frustration with NP prescribers. Maybe I started this discussion with Perception vs. Reality where I referred to a NY Times article titled "Making Patients Happy Doesn't Make Them Well."

First let me say that I work in two settings: I have a solo private practice which is a bit of an idealized bubble-world where I practice psychiatry exactly as I want and I make all the rules (and I never argue with the boss!) and I work as an outpatient Community Psychiatrist, where split therapy is the rule. In this setting, patients are seen for psychotherapy by social workers, sometimes they also have case managers, and the psychiatrist sees them to assess symptoms and prescribe medications. If all is going well and no one is complaining, the patient is seen by a doc every 3 months. If things are not going well, the patient is seen more often, and in the clinic where I work now, the therapist usually is present during the medication management sessions and communication is good. This helps. I started my private practice so I would be able to see patients for psychotherapy, and keeping with my bubble-world wishes, I don't see patients who have another therapist. I've never told someone who is happy with their therapist to stop seeing them, I simply recommend they consult a psychiatrist who has a working relationship with their therapist.

The reality of the world (bubbles aside) is that there aren't enough psychiatrists for everyone in every income bracket in every locality to see a psychiatrist for psychotherapy. That's just how the world is and that's fine. The other reality is that often people in split therapy like their non-MD psychotherapists (and as many have pointed out, often they like them much better) and get good symptom relief from medications prescribed by a doctor who sees them for 15 minutes a month, and they are pleased with their care and have great outcomes.

So why do I think that the best care comes from having one practioner do both therapy and prescribe? Really, it's not the politically correct thing to believe, but I do anyway.

Here are some reasons:

  • One-stop shopping is more convenient.
  • It's probably cheaper than seeing a psychologist and a psychiatrist (most PhD level psychologists I know charge as much as psychiatrists).
  • A psychiatrist who does psychotherapy really gets to know the patients--they aren't just a compilation of symptoms listed on a page. Psychiatric symptoms are often very similar to normal reactions and a psychiatrist who knows a patient well gets a much better feel for when a "symptom" is something other than an indication that a medication needs to be adjusted. Similarly, people often explain away their symptoms and a psychiatrist who follows a patient closely gets familiar with symptoms that could easily be written off and not treated appropriately with medications.
  • Being in psychotherapy with a psychiatrist encourages the patient to look at the relationship; in split therapy the patient may avoid looking at important feelings, and if the dynamic gets set that the therapist is the good guy and the psychiatrist the bad guy, the therapist may collude with this in a way that stymies the patient's ability to progress.
  • Non-MD therapists (and alas, some psychiatrists) may overlook or explain away episodes of major mental illness such that the patient never gets an appropriate referral for medications. Here lies the risk of Perception versus Reality: a patient may have a perfectly good, caring, helpful relationship with a therapist, feel comforted and understood, but not get Cured (or managed, or have symptom reduction, or optimize their ability to function) because a diagnosis is missed.

So the comments last time, when I agreed with that Shiny Happy Person, talked about how psychiatrists are lousy therapists. Some psychiatrists are lousy therapists. Some psychiatrists have no interest in doing psychotherapy. Many psychiatric practices are not set up for the psychiatrist to do psychotherapy. Some psychiatrists are creeps.

Medications are sometimes helpful when prescribed by a creepy psychiatrist with the social skills of an iguana. Psychotherapy, however, requires some degree of connection, some sense that the therapist can empathize, and without this it simply doesn't work as a treatment modality. There's not a therapist out there who is the perfect therapist for every one, and some people don't like even the best of psychotherapists.

So for my ideal, politically incorrect bubble world: Patients get the best of care when they see a psychiatrist (one they like and are comfortable with) for both psychotherapy and medications.