Monday, December 13, 2010

Prescribing Psychotherapy: Today's Grand Rounds at Johns Hopkins



Today, I heard Dr. Meg Chisholm give Grand Rounds at Johns Hopkins Hospital on "Prescribing Psychotherapy." Coming at it from an obviously pro-psychiatrist-as-psychotherapist bias, Dr. Chisholm discussed the financial forces that encourage psychiatrists to have "med check only" practices. She mentioned Daniel Carlat's book, Unhinged, and even showed a picture of it --she gave it a thumbs up. Meg quoted someone as saying that psychiatrists are a precious resource and should only be doing time-efficient psychopharmacology and presumably cranking through those patients as fast as possible. She showed bar graphs that illustrate how fewer shrinks are doing psychotherapy and fewer patients are getting it. In terms of cost, it's not clear that split therapy is cheaper, and psychiatrist-for-meds/psychologist-for-therapy is actually more expensive than one-stop shrinking. She made the excellent point that while we know that a combination of therapy and meds works best for some conditions, we don't know if people do better if they have therapy with a psychiatrist or split therapy with two mental health professionals, and we really need outcome studies. Finally, she talked about what role, if any, psychotherapy training should have in the education of psychiatrists during residency.

There was a portrait of one of our mentors, the late Dr. Jerome Frank, a pioneer in psychotherapy researcher at Hopkins. Meg showed a photo from his younger days, but I chose one of Dr. Frank as I remember him (see above). There was the requisite cartoon of a psychoanalyst, and a picture of the fictional Dr. Paul Weston (Gabriel Byrne) over his In Treatment couch. Ah, but Meg has it wrong--- she's never watched the show yet her research revealed that Paul is a psychiatrist who prescribes medicine, but Paul is a psychologist with training in psychoanalysis. No prescription pad and we never see him actually practice psychoanalysis.

A psychologist in the audience made the point that the experience of doing split therapy is very different when done with different psychiatrists, and that it's a totally different event with a primary care doctor.

My thoughts? I had a few.

-- I don't like the implication that psychiatrists "should" practice a certain uniform way. "Should" every psychiatrist have to do psychotherapy even if they hate listening to the same patients? "Should" every psychiatrist see four patients per hour even if they would much rather practice psychotherapy? Doctors should do what they do best and like best, and it's fine if some docs do psychotherapy and some docs don't. Would we dictate that doctors in shortage fields shouldn't be allowed to hold administrative positions, do research that could be done by Ph.D's, take maternity leave, pursue hobbies, or have blogs?

--There's more to psychotherapy than just psychotherapy. Seeing patients often and for in-depth sessions allows for a more careful use of medications. In clinic settings where patients are seen infrequently and everyone's expectations are for 20 minute visits every 90 days, it's very difficult to address the question of whether a stable patient might do better on a different medication regimen. The risk of stopping a medication is often riskier than just continuing with the status quo. The question "Are you the best you can be?" doesn't get addressed and major changes in medications usually happen during periods of crisis or hospitalization.

--Psychotherapy continues to be an integral part of psychiatric treatment and residents should be required to learn to do psychotherapy even if they never plan to do it again. Without seeing patients through the process, a psychiatrist can't really appreciate the benefits or limitations, and the while we might like to think that psychotherapy is something one "prescribes" just like bactrim or synthroid or insulin, we all know that some people feel more helped
by therapy than others and the importance of the interpersonal rapport is not something one can generically dictate.
----------------
Really good Grand Rounds.

Related Post: The Psychiatrist as Therapist

38 comments:

moviedoc said...

Psychiatrist, maybe all doctors, should be trained in prescribing the right brand of psychotherapy for the patient, just like they should be trained to prescribe the right drug or other procedure. Individual psychiatrists have a right to decide what they do and how they practice. Requiring all patients to attend weekly psychotherapy sessions in order to get medication makes about as much sense as requiring a diabetic to spend an hour each week with a dietitian in order to get insulin prescriptions. (The term "split therapy" is pejorative and reveals a bias. The term "independent treatment" is more neutral, therefor preferred.)

tracy said...

Thank you for an excellent post. "Independebt Therapy" has never worked for me (or i have never worked it). That is why now, i am seeing no one. Because i can't find a Psychiatrist who does therapy...my "last hope" "died" last week.

tracy said...

"Independebt"? Ooooooooh, Freudian Slip????????

Hee Verification is "lifeduck"

Gotta love it!

Anonymous said...

As an attorney who is court appointed for the alleged incapacitated on civil commitment proceedings, I love getting the psychiatrist who has only seen the respondent for 15 minutes. I may lose the case but at least I get to have a field day with the arrogant doctor.

Sarebear said...

Tracy, your word verify and "independebt", funny! If you don't mind me saying so, hee!

Sarebear said...

I had never thought about split therapy with a psychologist/psychiatrist being more expensive then doing both with a psychiatrist, before.

The point is probably academic with me, though, since I have such a hard time out here finding psychiatrists who are taking new patients, at all, let alone narrowing the field that much further to the few who may practice both psychopharmacology AND psychotherapy. I think I'll make it a question I ask, if I should ever be looking for a new psychiatrist again, not that I'm considering ending therapy with my psychologist, but he's about 60 and so I don't know when he might retire; I don't know if I can CHOOSE a psychiatrist based on this, should I be looking for one again, but I may find out my options and not settle on one until I've checked at least 20 different ones to see if a psychotherapy-practicing one is available. Also, since I don't know what insurance I'd have at that point, I don't know if it would mandate split therapy, or cover both therapies with one provider.

I also don't know if Medicaid splits the therapy, either. I suspect that, at the Behavioral Health place for my county, that they probably do.

But you gave me something to think about, especially since I don't know if my psychologist plans on retiring at 62, 65, or whenever (don't know how long I'll be in therapy, either.) I've also wondered about a couple of wacky things my psychiatrist has said lately; if she keeps that up, I may end up searching again at some point, but the need to get the mania under control, let alone the suicidal ideation, is too high right now to even consider a new psychiatrist. Best to stay the course, for now.

moviedoc said...

There are certainly advantages to having a psychiatrist provide psychotherapy as well as medication management, but there are advantages to getting the two from separate professionals, too. It's like using a spork vs. a separate spoon and fork. Do you really want a sporkiatrist to treat you?

Anonymous said...

sporkiatry has worked best for me. can't see what is pejorative about the term split therapy unless applied to a marriage counselor.

katie said...

this is one of the best posts i've seen from you. aside from the financial side (after going through several major insurances over the years, i've found that most psychiatrists who do therapy don't work with insurances; far easier to find med. management MDs and psychologists who will), I much prefer a model with a psychiatrist who also does therapy. the person simply knows you better, is better able to work with you, and can, perhaps most importantly, tweak meds on an as needed basis rather then needing to wait for a month or two to make a change. i also don't have to deal with feeling ashamed or uncomfortable about calling a med. mnagement person who doesn't really know me because he only sees me for 15 or 30 or 45 minutes every few months to let him know I'm breaking down and thus putting off a necessary med change; the psychiatrist-therapist model inherently prevents that. I've had med. management drs who were awesome during periods of even up to a few years while I was stable and healthy, but when things are shaky, the split/independent/whatever model just doesn't work. I don't think psychiatrists shoudl be forced to practice in a way they don't want to, but I also think a psychiatrist-therapist model is ideal, if not always practical.

Anonymous said...

I don't just think the drs should have to learn it, I think they should have to participate in it. Both because most of them need it and because without being on the other side, it is too easy to dismiss clients.

moviedoc said...

Note that Katie didn't say the sporkiatrist's psychotherapy skills are any better. All she seems to want is a psychiatrist who will know enough about her case to address some questions by telephone, see her as frequently as needed, and spend enough time with her, even if it's 45 minutes, to do justice to her treatment. And if it takes 45 minutes for patient and doc to adequately address meds and other questions, which it sometimes does, there is no psychotherapy going on, at least during that visit.

Anonymous said...

moviedoc, I am not answering on behalf of Katie, but I have to disagree that if it takes 45 minutes to deal with meds there is no psychotherapy going on in that session. the sporkiatrist will spend a good deal of time trying to figure out with the patient why the meds are not working NOW. could be that a major life crisis is throwing things off and could be that a med change is not really in order but rather some discussion of what is happening in life and how best to cope with that. with someone the patient sees for 15 minutes, it is easier to make a med change and forget to ask if your best friend is dying which could be the reason that you all of a sudden cannot sleep on a dose that worked before, or why you feel more anxious. sometimes it is worth looking at the anxiety and saying, anybody going through this would have a tough time and this is not a sign that we need to change meds. i have seen sporkiatrist and said meds are not working. since my next appt is way sooner than a month or more away we can afford to really examine the whole picture before making a change and sometimes we end up deciding to leave the meds as they are for a few days to see if things settle. so yes, that is a huge benefit to having someone who knows you well enough to pick up on other stuff

moviedoc said...

Anon, in my opinion real psychotherapy is more than just getting to know someone, and even in psychotherapy, which is always an artificial, controlled relationship the psychotherapist doesn't really get to know the patient. Real psychotherapy is treatment of an illness. If it's just a feels good, get to know me thing, it isn't health care, which is not to say it isn't worthwhile or helpful. And this isn't just about patients with psychiatric illnesses. All patients need adequate time with their docs.

tracy said...

Sarebear Glad you liked it :)

Anonymous said...

moviedoc, where did you get the idea that i thought psychotherapy was just about getting to know someone? of course it is an artificial, controlled relationship. it has zero to do with "feels good", although if it feels really bad all the time, get out quick. when i say the psychotherapist knows the patient better i mean that they have built up a level of familiarity with person x and are likely better able to pick up whether something seems different about that person and try to understand what is going on. with a meds only doc ,who is seen infrequently and for very short periods, it can be tough for them to really be able to get to the bottom of something. my neighbor does not really know me, and that is an artificial and controlled relationship--fake the hi how are and how is the family smile, offer to watch their house when they are on vacation but even if that is all it is, the familiarity over time makes it more likely they , and not the cashier at the grocery store, will figure out i am dead if they don't see me for 3 months.
all that said, i don't think that anyone should have to have psychotherapy as a prerequisite to getting meds and it is clear that not all docs want to do psychotherapy and to be sure, the world is better off if the ones who do not want to do it don't.
familiarity does not necessarily mean good psychotherapy and while there are plenty of lousy therapists out there, i can think of some meds docs that should really be UPS drivers.

Anonymous said...

moviedoc, where did you get the idea that i thought psychotherapy was just about getting to know someone? of course it is an artificial, controlled relationship. it has zero to do with "feels good", although if it feels really bad all the time, get out quick. when i say the psychotherapist knows the patient better i mean that they have built up a level of familiarity with person x and are likely better able to pick up whether something seems different about that person and try to understand what is going on. with a meds only doc ,who is seen infrequently and for very short periods, it can be tough for them to really be able to get to the bottom of something. my neighbor does not really know me, and that is an artificial and controlled relationship--fake the hi how are and how is the family smile, offer to watch their house when they are on vacation but even if that is all it is, the familiarity over time makes it more likely they , and not the cashier at the grocery store, will figure out i am dead if they don't see me for 3 months.
all that said, i don't think that anyone should have to have psychotherapy as a prerequisite to getting meds and it is clear that not all docs want to do psychotherapy and to be sure, the world is better off if the ones who do not want to do it don't.
familiarity does not necessarily mean good psychotherapy and while there are plenty of lousy therapists out there, i can think of some meds docs that should really be UPS drivers.

moviedoc said...

Anon, I agree with most of what you say, and I did not mean to imply that you said psychotherapy is just getting to know someone. Sorry. I have heard this getting-to-know-you justification elsewhere, too. However, I may have a higher opinion of UPS drivers than you do.

katie said...

Moviedoc, I think you completely misunderstood wht i was saying. Maybe it wasn't a clear post. I definitely do not want a psychiatrist who knows enough about my case to answer questions by phone as needed. When I said that a plus of the psychiatrist-as-therapist model is that meds can be tweaked as needed, I meant that meds can be tweaked as needed. That is, therapy is going along, etc, and a mood slips, or a med needs adjusting- the psychiatrist-as-therapist model can answer that asap (ie as needed)) as opposed to needing to contact the med. management psychiatrist to then make an appt -- and to deal with all the baggage that inevitably recurs when one must call a psychiatrist after doing fine for a while. Same token - as I said before - a psychiatrist-as-therapist who's treating someone on a regular basis knows that person, and his/her moods and symptoms far better then a med management dr who sees a patient once every month or three for 15-20 or even 45 minutes. No question about that. And yes, agreed with previous posts about therapy not being about simply getting to know you or feeling good.

I don't think all doctors should need to practice psycotherapy. I've had periods of 5+ years where life was stable and all I needed were3 month med checks (and I resented needing to interrupt my health, stable life to see my psychiatrist, who I liked alot, every single time) and there was no place or need for therapy. I do think all psychiatrists should have training in psychotherapy. It is an inherent part of treating psychiatric illness. aAnd I do think, most of the time, psychiatrist-as-therapist is unquestionably the ideal (aside from financially).

Sunny CA said...

Moviedoc_

I think that to call an MD psychiatrist who handles both medications and psychotherapy a "sporkiatrist" is insulting and demeaning to what I consider to be the absolute Gold Standard of mental health care, the psychiatrist who does both med management and psychotherapy. I think perhaps two thin layers of wood alone versus the same two thin slices glued together into plywood would be better, or perhaps a metal alloy being better than either metal alone.

Psychiatrists trained in psychotherapy who care about doing psychotherapy are better than psychologists and other types of therapists at doing talk-therapy in my opinion. Whether their training is better or the selection and training process (due to the necessity of first going to medical school) being more rigorous just sorts for better people, I don't know.

The biggest failing of the meds-only doctors in my opinion is the potential for inaccurate diagnosing due to severely limited assessment time, and the attendant "jumping to conclusions" that results. When I had a meds-only psychiatrist, he would put words in my mouth, repeating back to me things I never said because a maybe or I-don't-know to a question meant "yes" to him, plus it went through a filter in his mind popping out as something completely different (similar to the way you leaped from Katie's saying she prefers a doctor who can "tweak meds as needed" to your interpretation of that being to "know enough about her case to address some questions by telephone"). That is a perfect example of how my meds-only pdoc would warp what I said and how frustrating it can be for a patient who has a med-doc who does not listen, makes assumptions, jumps to conclusions, and makes a wrong diagnosis. If a patient were talking to a psychiatrist for 50 minutes 1-2 times a week there would be a greater chance that the patient could correct the psychiatrists mistaken assumptions. The psychiatrist who has chosen to do psychotherapy also probably is more inclined to actually LISTEN to a patient, rather than cut the session short with a quick diagnosis because he put words in the patient's mouth.

moviedoc said...

Sunny, I disagree. I know many non-physician psychotherapists who are as good as or better than psychiatrists at doing psychotherapy. Part of the problem is that most psychiatrists can only do one kind of psychotherapy, psychodynamic. Few psychiatrists know how to do family psychotherapy at all. Talk about mistakes: See how much more a patient can be helped when the psychotherapist hears from others in their social network. And as for those mistakes that could be corrected by 2 50 minute sessions per week, you can say the same for a physician of any specialty. Let's see, plan on 2 sessions with the PCP, 2 with the cardiologist, 2 with endocrinologist, ad infinitum. Gee did I miss the optometrist and the dentist. What about lawyers? We all need to know how to listen, and without 2 sessions per week.

Anonymous said...

moviedoc, there you go again. who said i had a low opinion of UPS drivers? they deliver my stuff, usually on time, but they don't have to talk to me or too many other people and they certainly don't have to listen to me. so nay shrink doing psychotherapy who really doesn't want to and who can drive a truck would make a better UPS driver.

Anonymous said...

Not everyone who wants to be a psychotherapist, should be. And there may be some perfectly good listeners who are trained in psychotherapy who would rather squirt chemicals into petri dishes. Willingness, interest and skills are separate issues. I agree that people should have the freedom to do what they enjoy, but you can't assume skills based on choice.

Anonymous said...

trouble is how do you really test for skill in this profession?

tracy said...

Sunny Ca

"Well put, that was laid on with a trowl".

i agree with so much of what you said. The most excellent therapists i have had were Psychiatrists...it is such a shame that so few do therapy now. :(

As for non-MD's....i have had the worst therapy with them.

moviedoc said...

Anon of the UPS drivers: Nay. 'Tis I waxing facetious with my low opinion of some of my colleagues, including a few who only do meds. I suspect the psychiatrists (sporkiatrists?) who still do psychotherapy are the ones who are good at it. Another reason it's probably no great loss that some have stopped.

tracy said...

moviedoc

i don't understand where you are coming from....

One of the very best therapist's i had, ever, was a fourth year Psychiatry Resident and he definanly did not practice Psychodynamic Psychotherapy. We did alot of work with Schema. i would imagine Psychiatrists are trained in many different types of therapy, if they are in a good program. i was in Psychodynamic Therapy once, it did me no good.

The really excellent Psychiatrists i have had the great fortune to be in treatment with did not practice Psychodynamic.

moviedoc said...

Tracy: I hope all psychiatry residents train in several types of psychotherapy, so they can intelligently "prescribe" the right type for the particular patient's illness, but it's hard to be really good at even one type. Then there's the question of how you judge a psychotherapist's skill. I suspect some of my patient's thought I was terrific, others that I was incompetent. Probably a lot depends on chemistry, like in Good Will Hunting

tracy said...

Thank you, Moviedoc

Definately chemistry. If the click isn't with you, the click isn't with you.

Midwife with a Knife said...

I find it really interesting that this is a debate in your field. In MFM, there are many different practice models (ultrasound only, ultrasound + Consult only, ultrasound + consult + deliveries + fetal procedures, etc).

MFM is historically also a "shortage" field, and my delivery skills are not necesarily better than a general ob/gyn (and may be less good in some cases), because my fellowship wasn't about delivering babies. It was about deciding when to deliver babies.

Within my practice we have a lot of conversations about what kind of a practice we want to be in 20 years, but we don't presume to think that our practice model is better than anybody else's, or that everybody should have our model. We just try to fit our model to our community as best as possible.

katie said...

moviedoc,
my guess is that you're looking at this through your own experience - as we all do, of course - but that you can't quite recognize it. for example, it's absurd to say that most psychiatrists doing therapy as well can only do psychodynamic based therapy. 30 years ago, I'd have agreed, even 15 years, but now, that's just a silly statement to make. Just as it's silly to take an analogy of seeing a dentist twice a week as equivalent to seeing a therapist weekly or twice a week. Not to mention that while in addictions psychiatry family therapy could be profoundly helpful and relevant, that's not necessarily the case for most other illnesses/reasons-people-seek-therapy on a regular basis, if at all. Seriously?

moviedoc said...

Katie: If you think that was silly, I hope you never watch some of my YouTube performances.

Dinah: Got any numbers? How many psychiatrists today would you estimate primarily do, or are most skilled at, psychodynamic psychotherapy?

Tracy: "To be a Virginian, either by birth, marriage, adoption, or even on one's mother's side, is an introduction to any state in the Union, a passport to any foreign country, and a benediction from the Almighty God." -Anonymous

Anonymous said...

moviedoc,
stick to watching movies. maybe people aren't your thing. i often try to imagine what my doc might be like in real life and if they were anything like the way you come across i would run for the hills whether i liked them as a doc or not.

tracy said...

Moviedoc :) ...by adpotion.."

katie said...

moviedoc: silly was meant to be mild. what i really meant was moronic and uneducated.

moviedoc said...

Katie, I know you don't like what I'm saying, and I respect that, but if it takes "moronic and uneducated" to get my point across, I'll do that and more.

Anonymous said...

Moviedoc, HBE: You are one scary dude.

Katie said...

moviedoc,
I understand what you're saying. I think everyone does, though you may not be understanding the posts that don't agree with you. You're not having any trouble getting your point across. Your point just isn't accurate, or based in reality.
I don't want to argue with you. You're entitled to think what you like. But I certainly do feel for your patients!

tracy said...

Insurance Quotes i completely agree! Oh, to find one! i guess i have been totally spoiled in my past...