Do psychiatrists still do psychotherapy?
Until the end of the last century, people with mental illness generally consulted a psychiatrist for all their treatments. Trained as a physician, a psychiatrist would assess possible medical causes of psychiatric symptoms, such as hypothyroidism, anemia, and high blood sugar.
The psychiatrist often performed the admission physical examination if the patient was admitted to a mental institution. Then the psychiatrist would consider the indications for prescribing the limited number of psychoactive drugs available. And he was going to initiate psychotherapy. At that time, the primary treatment provided by a psychiatrist was psychotherapy. This model of treatment allowed the patient to be treated by someone with the necessary skills.
However, since the 1980s, the overall responsibilities of the psychiatrist have been divided. With increasing familiarity with psychotropic medications, many primary care physicians are willing to prescribe them. In “split” treatment approaches, a therapist, such as a licensed counselor, social worker, psychologist, or life coach, provides “talk therapy” while the psychiatrist (or other physicians) prescribed medication. Indeed, many psychiatrists avoid administering psychotherapy. A psychiatrist who presents himself as a “psychopharmacologist” or “neuropsychiatrist” claims a priority interest for the prescription.
A study analyzing over 20 years of data collected by the US National Ambulatory Medical Care Survey (NAMCS) evaluated the use of psychotherapy in outpatient psychiatric sessions. Psychotherapy has been defined as “all treatments involving the intentional use of verbal techniques to explore or modify the patient’s emotional life in order to achieve a reduction in symptoms or a change in behavior” in a session of more than 30 minutes. The study found that the psychotherapy practiced by psychiatrists more than halved between 1996 and 2016.
Additionally, since 2010, more than 50% of psychiatrists have provided no psychotherapy. Self-paid patients were more likely to receive psychotherapy. Patients younger than 25, black or Hispanic, or with Medicare, Medicaid, or HMO coverage were less likely to receive psychotherapy. Diagnoses of schizophrenia or bipolar disorder were less likely to involve psychotherapy.
Psychiatrists offering psychotherapy more often saw patients with dysthymic disorder, anxiety disorders including social phobia, PTSD and obsessive-compulsive disorder, and personality disorders. Psychiatrists prescribed psychotropic drugs at a higher rate for patients receiving no psychotherapy.1
Market forces have greatly influenced this shift in psychiatric practice. Insurance reimbursement programs strongly incentivize brief “medical check-ups” for psychiatrists and favor lower-paid non-physician providers for longer sessions. Increasing biomedical advances and the development of more psychotropic drugs have skewed the emphasis on biological approaches to treatment.
Although the Accreditation Council for Higher Medical Education requires psychiatry residents to acquire skills in cognitive, psychodynamic, and supportive therapies, many training programs are deficient.2 Psychotherapy training encourages the trainee to openly and self-critically expose themselves to a supervisor by describing their encounters with the patient. The residency program must also absorb the expense of hiring experienced faculty for supervision time. These requirements discourage the more demanding elements of teaching and learning psychotherapy. It is less demanding for residents and their teachers to focus on reviewing biochemical and dosage recommendations for medications drawn from lectures and readings.
Are psychiatrists relevant if primary care physicians can prescribe medication and non-physician clinicians can provide therapy? Split treatment can be advantageous when the therapist has specialized training in a particular treatment. However, multiple providers are inconvenient, communication between professionals is limited, and everything can be ineffective for the patient.
Integrated treatment by a psychiatrist who has more specialized knowledge of psychotropic medications than a family physician and experience with appropriate psychotherapy models may be the most competent provider of mental health treatment. For this traditional model of psychiatry to persist and not be limited to the role of “pill seller”, payment sources and training programs must more fully recognize the value of medical psychotherapy.
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