We Must Take Back Talk Therapies

By London, Robert T. | Clinical Psychiatry News, August 2009 | Go to article overview

We Must Take Back Talk Therapies


London, Robert T., Clinical Psychiatry News


The number of psychiatrists who provide psychotherapy is on the decline. Numerous studies have pointed out that psychiatrists are more focused on medication management, and that we typically hand over our psychotherapy patients to nonmedical therapists.

In addition, the general impression among many patients seems to be that it's best to go to psychiatrists for medications and therapists to do talk therapy.

It hasn't always been this way. For decades, psychiatrists were the sole providers of psychotherapy, with psychoanalytic or analytically oriented therapy forming the mainstay of clinical practice.

The reasons for the decline in the number of psychiatrists who do psychotherapy include the poor level of third-party reimbursement for "talk therapy," the success of pharmacologic treatments alone, and the view that reaching more patients by providing 15-20 minutes of medication management for three to four patients an hour is a more efficient method of care and affords better payment. From the third-payer perspective, nonmedical therapy is often less expensive for them, even though it is not necessarily better care.

Talk therapy (which I believe includes cognitive-behavioral therapy, behavior modification, and relaxation) does not have to be open-ended. It can be codified, goal-oriented, and short-term. One of the first psychiatrists to use cognitive therapy appears to be Pierre Janet, who, more than 100 years ago in his L'Automastime Psychologique, advanced the idea that thoughts can be challenged and that perceptions leading to mental problems can be reversed. It was not until Albert Ellis, Ph.D., in the beginning of the second half of the 20th century, and Dr. Aaron Beck a decade later clearly showed the positive, short-term successful effects of cognitive therapies that some recognition occurred.

After World War II, the competition for psychotherapy increased with the number of psychologists who shifted from research or animal studies to a more therapeutic role, and the possibilities of referrals to them and of them providing direct psychological care increased substantially. In direct competition with the psychologists was the burgeoning group of social workers who became mental health therapists--not to mention others who do practiced psychotherapy based on a wide variety of training and techniques, but who nevertheless provide mental health care.

The area of psychotherapeutic care appears to be in disarray at the moment, with so many different therapists offering different treatments and psychiatrists not offering psychotherapy. But psychiatrists should be in the leadership role rather than just focusing on medication management.

One new and interesting development is that psychiatrists are offering limited education to primary care physicians (PCPs) on how to medicate psychiatric patients. …

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