Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.And is there a problem here? You got the fancy-schmancy credential so you could charge more, and now you find that you'll need to get rich clients who can pay for your services, or you're lured into the drug-prescribing racket which doesn't amuse you that much. Face the consequences of your own decision, your own flawed effort at winning in the marketplace. Or do I need to sit you down and prompt you for an hour until you see it that way?
Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.
March 6, 2011
Insurance won't pay enough for psychiatrists to do old-style talk therapy.
Which makes life as a psychiatrist less rewarding, but really, why should people buying health insurance get stuck funding psychiatry sessions? If you want your talk therapy with a psychiatrist, you have to pay the premium for this luxury out of your own funds...
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65 comments:
Their time is up.
Is there a problem here? You got the fancy-schmancy credential so you could charge more, and now you find that you'll need to get rich clients who can pay for your services, or you're lured into the drug-prescribing racket which doesn't amuse you that much. Face the consequences of your own decision, your own flawed effort at winning in the marketplace. Or do I need to sit you down and prompt you for an hour until you see it that way?
Precisely - I swear, Ann, looove when you're on top of it.
Research shows that same number of patients do better without "talk therapy" after passage of one year as do well with it after the passage of one year. But at least you have a "friend' to unload on who doesn't tell everyone else.
I would rather be one of those poor bastards on an Alaskan crab boat than be a shrink. Without even getting into the validity of the science, can you imagine spending all day listening to other people's miseries? No way in hell.
"Or do I need to sit you down and prompt you for an hour until you see it that way?"
Great line, Ann.
More of this please for other areas of health care, and the law.
From the article--
“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 said. “But one by one, we accepted that that craft was no longer economically viable. Most of us had kids in college. And to have your income reduced that dramatically was a shock to all of us. 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.”
He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”
“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”
From Beyond Meds--
There you have it. “Fuck the patients, I want to have a good lifestyle.” Unfortunately this is most likely much more common than one would think. Practicing professionals who consciously choose to not do what is best for a patient so that they might get paid by insurance and live superior lifestyles to most of the population (and most all of their patients).
http://bipolarblast.wordpress.com/
I thought the Althouse blog was free therapy?
Collective therapy perhaps.
@chickelit
There is certainly enough listening to other people's misery to qualify as group therapy.
One afternoon this psychiatrist gets a frantic telephone call. "Doctor, my name is Mary Jones, something terrible has happened! It's my son Johnny, earlier today he went to the playground with the six-year-old girl who lives next door, they were going to play on the swings, but some people heard this giggling sound, and they were found behind the bushes with their pants down! I don't know what to do!"
"Please calm down, Mrs. Jones," the shrink replies, "it's perfectly normal for children to be curious about each other's bodies and to explore like that."
"Well, I still am frantic, Doctor. And if you think I'm bad, you ought to see my son's wife."
Peter
What psychiatrists have to offer is the ability to write Rx's for psychotropic drugs that people want. Don't most people realize by now that the bitch-bitch part of the session is a lot of wasted time? Granted, some people like it. Some sort of support group like AA would probably suffice for them.
Harry - read the article on the importance of talk, even remaining within the meds only realm. You absolutely MUST talk.
There's just tons of preventable deaths that happen within hospitals and via drugs, and I'm talking about the whole realm of meds, not just psych meds. Talk is central.
why should people buying health insurance get stuck funding psychiatry sessions?
Well the simplistic answer is this. Unfortunately, long ago, intentionally or otherwise, psychiatrists found themselves dealing far more with psycho-pharmacology than talk therapy. And as long as the non physicians have limited prescribing privileges its the most lucrative place to be for psychiatrists. I don't see a great future for psychiatrists. By taking this route they've establishing non-psychiatrists as the backbone of the mental health system. It will only be a matter of time where either by easing of regulations or by economics that they will find themselves left behind.
(More than half of all psychiatrists are 55 or older, while the number of medical school graduates going into psychiatry is dropping)
Around here, the problem isn't so much this as it is this.
wv = mulatomi
Troop would say that mort would say that's racist.
Man, when the NyQuil goes in, all the inhibitions come out.
Sounds like some insurance companies just want to cut corners. Psychiatry is a mix of analysis and medication when necessary, but putting a social worker in the same boat as one is a joke and psychologists aren't always equipped to do the same thing.
The beauty of AA is the talking. I once attended a session as part of a class assignment, and was very touched. It was in a church hall, with about 25 members arranged in a circle.
My dad was a bad alcoholic for many years, and only in the last 15 years, or so, staightened up, but not with AA. He tried it in younger years but it didn't take. But he highly recommended the AA blue book.
He was raised with an emotionally damaged mom, who had lost her first husband early. She never hugged her kids. Never. Can you imagine? For all that, she was a good mom otherwise, but she raised three alcoholics and one pill popper.
Anyway, I think one of the root causes of alcoholism is inability to express feelings. At the session I attended, people talked, and simply got it out. Not tears and wailing, just talk.
Because some problems require talk therapy.
Medicine alone won't fix a problem that isn't based in biology.
$600an hour is ridiculous though.
"If you want your talk therapy with a psychiatrist, you have to pay the premium for this luxury out of your own funds..."
I think that's a bit harsh. I have a child in their 20's who suffers from NDPH, chronic disabling migraines since the age 13. If it were not for "talk therapy" my child would not still be here. Taking a pill and hoping for the best just doesn' cut it when dealing with the despair and depression from living in constant pain for years without hope. These therapy sessions are not a luxury but a necessity.
You got the fancy-schmancy credential so you could charge more, and now you find that you'll need to get rich clients who can pay for your services, or you're lured into the drug-prescribing racket which doesn't amuse you that much. Face the consequences of your own decision, your own flawed effort at winning in the marketplace.
This is rich coming from someone whose income comes from a methodology now 120 years old that required the fewest salary-drawing professors while extracting tuition from as many students as possible. If not for the notion that some schools are better than others, implemented by a third-rate (now defunct) news magazine -- with some 14 routinely scoring in the top ten -- all lawyers would efficiently and cost-effectively study law online.
A heretofore normal guy wakes up one day, and instead of getting dressed he wraps himself in Saran Wrap and takes a walk. A few minutes into his walk he realizes what he's doing and runs panicked to the nearest psychiatrist's office. He rushes in and exclaims "Doc, what the hell is wrong with me?" and the Doctor replies, "I can clearly see your nuts".
"I thought the Althouse blog was free therapy?"
Yes, but see the PayPal button in the sidebar. You can make a contribution here, and I genuinely appreciate the contribution.
Jenny and Lisa, the question is not whether the patient requires talk therapy, but whether they require talk therapy with a psychiatrist, rather than a psychologist or social worker. Does it make a difference in the circumstances that you are describing?
Maybe it does, I really have no way of knowing. But I'm skeptical. And if it doesn't, insurers definitely shouldn't be covering the pricy psychiatrists where a cheaper option is available.
- Lyssa
Lyssa,
For me the answer is obvious - psychiatry is about the most useless profession there is. Having said that, because they engage in such dangerous behavior (prescribing psychopharmaeuticals on the fly), it is absolutely incumbent upon them to indeed talk to their patients. As I said to Harry - read the article to see why. At the end of one of his conversations, the good doctor realized he had misdiagnosed his patient. You have to talk to patients to see how they are reacting to these, in most cases, useless drugs. It is absolutely essential. Otherwise, you're right, for talk therapy go see a therapist of a psychologist with a PhD. Or your minister, or your friend, or group therapy. No need to waste time talking to a drug dispenser, you are correct (if you are not getting the drugs).
Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash.
Reminds me of a (very) lefty acquaintance of mine who's a counselor. She refuses to take TennCare patients because she gets paid a lot less. (But of course, anyone against universal healthcare is an asshole.) She's sweet, actually, just totally clueless.
"I think that's a bit harsh. I have a child in their 20's who suffers from NDPH, chronic disabling migraines since the age 13. If it were not for "talk therapy" my child would not still be here. Taking a pill and hoping for the best just doesn' cut it when dealing with the despair and depression from living in constant pain for years without hope. These therapy sessions are not a luxury but a necessity."
Why is a psychiatrist -- a medical doctor -- required to do what can also be done by a psychologist or psychiatric social worker?
(I see Lyssa already said it.)
I think psychiatrists should follow the example of my old pal Ronnie Laing and move into a big house with a bunch of schizophrenic patients.
Lyssa,
Having never had talk therapy, myself.. I can't answer.
I do know my insurance won't pay for therapy with a social worker, only a psychiatrist or psychologist.
My two family members who have had talk therapy for PTSD have had different levels of care. One was cared for by a psychiatrist who handled her medications and her therapy; she didn't get quite the intensive level of therapy that she should have been because this was workman's comp. The other one, also struggling with PTSD, has medications provided through TWO separate psychiatrists but is under the care of an extremely experienced and skilled psychologist who used to work in-patient at our research hospital here in town. The coordination between the psychologist and the psychiatrist has been relatively behind the scenes but I suspect that is because these three gentlemen have worked together for many many years.
Having said that, the psychiatrists at our local research university have too large a patient load as it seems impossible to get a same week appointment.
Talk therapy amounts to the patient figuring out what activates a barely perceptible smile of the therapist's lips and offering up that formula before the session ends because for a small fortune you've gotta get something out of the bastard!
There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.
We should remember do not believe everything you read. Has there ever been a study of trial outcomes for a client charged with murder comparing those defended by someone with 2 years of law school and someone who is a member of the bar and has worked in an office doing criminal defense for 5 years?
There actually was at least one study some years ago that showed if you let a person see a psychiatrist once a week for 4 weeks they did better and overall cost less than seeing a non-psychiatrist therapist.
I hope none of you ever have a suicidal child or teenager in your family to find out the hard way.
Yes, but see the PayPal button in the sidebar. You can make a contribution here, and I genuinely appreciate the contribution.
I have given in the past. The kind help I was talking about is freely given by the commenters.
I have a somewhat negative impression of social workers, through the ones that I have known throughout my lifetime. I remember one, who was working on her MSW while we were together. She told me that she had moved to Colorado to be with me, and if I left, she would kill herself. So, I did, and, 30+ years later, she still hasn't.
That said, I would suggest that the average PhD psychologist is much better trained in analysis than their MD psychiatrist cohort. While the MD was learning how to cut up cadavers and deliver babies, the psychologist was learning about how minds work.
That is not to say that there are not a lot of places where psychiatrists are valuable practitioners. I know several who specialize in pain management and others who do brain research, several, for example, looking for cures for Alzheimer's.
But I don't think that the one-on-one talk therapy, or, indeed, group therapy, is working to their strengths. I just don't see MD being worth that much more than the PhD, or maybe even the MSW in these areas. Or worth even, maybe, any more.
I suspect psychiatrists are a bit smarter than psychologists and social workers. At any rate, with all the years in medical school and residency, there's a better chance the flakes will get screened out. (Maj. Hassan notwithstanding.)...The quality of the relationship and the wisdom of the advice are more important than the professional qualifications of the therapist. That said, your odds are probably better with an MD than a MSW. The fees are high, but rich people spend their money on much dumber things.
Finally something I know a lot about on a personal level. My youngest son was diagnosed with OCD two years ago and one of the many things we learned through this very difficult journey was the fact that psychiatrists simply do not do therapy. They only prescribe meds. If you want therapy you have to find a psychologist - of which there are several types, including people with doctorates in psychology or masters degree in family counseling or doctorates in education. I won't bore you with the chore of finding one of those - it's a tremendous one one - but I will say that in the end psychiatrists are useless. We tried two and finally ended-up just having our family practitioner prescribe and monitor our son's meds. He's known our family for years and knows our son well, so we trust him more than some specialist who spent five minutes with our son, prescribed a pill and said, "Come back in three months."
End result though, we found a great therapist (doctorate of education) and our own doctor has managed the meds wonderfully, the result being our son is doing very well.
Now as to the concern here with talk therapy being paid by insurance. If it's to deal with some rich person's depression over which of their two homes to visit during the holidays, I agree totally. But I've seen just how helpful and important these sessions with my son's doctor have been to his well-being. (Of course, it isn't really talk therapy but Cognitive Behavior Therapy the only true treatment for OCD).)
In case I was unclear, when I say my son's doctor I mean the psychologist.
The amount of talk therapy is diminishing, period, be it provided by psychiatrists, psychologists, social workers, or housewives. Health Insurers discourge the use of talk therapy simultaneously promoting the use of pharmaceuticals (which have exploded in their use for psych disorders over the past few years, especially with kids). On the other hand, the boards of directors for these health insurors and big pharma share members in common. Both insurance companies and big pharma have the funds to buy off our politicians and generate some of the best pr and propaganda that money can buy to shape public opinion. See for example the following article
From Evidence-based Medicine to Marketing-based Medicine: Evidence from Internal Industry Documents
Glen I. Spielmans and Peter I. ParryJournal of Bioethical Inquiry Volume 7, Number 1, March 2010
Available at
http://i.bnet.com/blogs/spielmans-parry-ebm-to-mbm-jbioethicinqu-2010.pdf
The idea that psychotherapy is for rich whiners as opposed to people with real (and fatal)illnesses pisses me all the way off. You seem to have turned into a crank, Althouse.
Hey, TWM, my 41 year old daughter has been burdened with OCD since she was diagnosed as a teenager. She was part of the first NIH study to see if a particular medication would prove helpful. Fortunately, it did to some extent so they stopped the double blind study so all the kids could get a chance at taking the non placebo.
Anyway, OCD is a toughie but it seems like your son has the best support system arrangement possible. I pray that sometime in my daughter's lifetime, science comes up with a true miraculous cure. My heart is forever heavy as I think of the lack of peace she has with her brain.
Psychiatrist about to phone his wife.
This is the second day in a row I've had a use for the old Thurber cartoon.
“I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications.”
In that case, it should be pretty easy to put together a program to certify psychologists to prescribe the medications. Which would restore the situation of people getting deep, detailed talk therapy from the same people that give them their meds.
Of course, that would drive psychiatrists completely out of business in favor of psychologists, as the last function gatekeepered by medical school is eliminated.
Some diagnoses are difficult and are only correctly made after relatively long periods of office visits. Correctly diagnosing bipolar disorder can take on average two years. Even for "easy" diagnoses like depression, finding the correct medication and dose for a given patient can take a long time of regular visits between the patient and psychiatrist. That said, a psychologist can do therapy as well as a psychiatrist if the meds have been figured out.
Acceptance of evidence based medicine all depends on whose ox is being gored. Insurance companies know not to touch mammograms.
"I thought the Althouse blog was free therapy?"
Yes, but see the PayPal button in the sidebar. You can make a contribution here, and I genuinely appreciate the contribution.
Hey, I'm an AA team player ;) just trying to help her cause ...
A follow up-
I agree one does not have to have a MD to be good at "talk therapy", but that does not mean all therapists are equivalent.
Some people are very gifted and skilled at what they do, whether it is an NFL player from a small school or a MSW doing counselling. But in general the more training and the more competitive it is the better one gets. I would agree that some psychiatrists are not the best talk therapists, and even some who are find themeselves doing med management and oversight of less trained counselors. Someone with a PhD or PsyD has put in additional years of training and their own research.
Everyone knows the concern over increased suicidality in youth on antidepressants. This actually is nothing new, it's just that 25 years ago a doc would never write a script for an anti-depressant and say "see you in a month". You wouldn't give enough medicine for more than 2 weeks, and it would be at a low dose to begin. If a patient became suicidal the doc could catch it. Newer drugs that are "not as dangerous" and other changes in the practice of medicine led to this (unfortunate) change.
The benefit of having a psychiatrist who specialized in adolescents was vital due to the fact that he was able to both explore medical treatments in collaboration with neurologists and also deal directly with the social/emotional and developmental issues. A therapist is not able to prescribe and because of that, limited the ability to deal with complicated medical issues as well. Once stabilized I suppose a certified therapist could take it from there. Under this circumstance a social worker would be useless or worse.
All the way through the comment section and no mention of the Bartender Talk Therapy method?
(Not meaning to make light of those in this thread who have real problems and troubled family members)
“I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications.”
- That's a bit like saying there's nothing to hitting a baseball, you just swing the bat. Everything is easy when things go according to the original plan. Yes, probably 75% of depressed adults would respond to meds without a psychiatrist, which is a darn good thing as there aren't enough psychiatrists to see many more.
themightypuck said...
"Acceptance of evidence based medicine all depends on whose ox is being gored."
- Absolutely. I chuckle at the term, as if prior to 1995 medicine was not based on evidence but voodoo and astrology.
There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.
I'd like to see the evidence of how much good any of it does. My father was a clinical psychologist and a professor of clinical psychology. I remember him telling me about a study that showed talking with a young, relatively attractive, sympathetic female was more effective than traditional therapy.
There is plenty of anecdotal evidence of individuals "helped" by talk therapy. But, overall, are people really helped significantly? We have many times the number of therapists now than we had 50 years ago. Are people less crazy? Are we more successful in relationships overall? Are we doing a better job of raising our kids? How are we performing as a society on these and other various other measures of mental health? Not any better than we were 50 years ago in my book, probably worse.
traditional guy said:
"Research shows that same number of patients do better without "talk therapy" after passage of one year as do well with it after the passage of one year. But at least you have a "friend' to unload on who doesn't tell everyone else."
Not true. Psychotherapy works. Even Consumer Reports says so.
This reads like 'The Sun' magazine. I read it because it makes me feel grateful not to be like those crazies and liars.
"I pray that sometime in my daughter's lifetime, science comes up with a true miraculous cure. My heart is forever heavy as I think of the lack of peace she has with her brain."
Michaela,
I know exactly how you feel. While my son is doing very well with his combination of meds and therapy, we know this will be a life-long struggle for him. Like all parents who find their children facing a serious illness, it's a pain that is hard to describe unless one has experienced it.
Finding a good therapist - who is more likely going to be a psychologist and not a psychiatrist - is essential. And one that does CBT is mandatory. Meds can be managed by any competent physician as long as they consult with the psychologist and know their patient.
Jenny said: "The benefit of having a psychiatrist who specialized in adolescents was vital due to the fact that he was able to both explore medical treatments in collaboration with neurologists and also deal directly with the social/emotional and developmental issues."
Good luck finding one. Maybe in the big cities like NY and LA, but in my neck of the woods (Nashville) the two I found only wanted to prescribe a pill and move on to the next paying patient. The others I checked with were at major hospitals running studies where you never talk with the doctor, only his clinical assistants.
There's a story in the NYT regarding the lack of a need for attorneys. I would suggest that Professor Althouse, too, should "face the consequences of your own decision, your own flawed effort at winning in the marketplace." I guess just about everyone these days needs to face the fact that jobs and times change. No need for attorneys? Clearly no need for law school professors who, from what I can tell, do very little real work, anyhow.
http://www.nytimes.com/2011/03/05/science/05legal.html?_r=1&ref=science
Wonder if Althouse also caught the article in the NYT today by the public editor that reminds us again that it will eventually take money to access the Times on-line. What will she do then, when the source of such readily available material to criticize costs money? Complain and explain how many readers she brings to the NYT site and how valuable she is to the site? Or adjust and get rich clients who will pay for the chance to read the original articles?
You know what's really helpful? Books.
mimoore —
I'm not the one saying meds are easy. It's the psychiatrist from the article who's saying that they are; I'm just deferring to his expertise and pointing out the logical conclusion of his statement.
A psychiatrist has the full arsenal of techniques at his or her disposal: talk or pills. Psychologists cannot write prescriptions. And in fact, there is not a pill for every ill. Moreover, in many cases the cure is worse than the disease: the depression cure that gives the patient the strength to take his or her life.
People who have to pay others to talk to them are no different than those who have to pay for others to have sex with them. I don't see anything wrong with either practice but I don't see the need to subsidize them either. And if I had to pick one of the two it sure as hell would not be the talk therapists.
ken in sc said...
This reads like 'The Sun' magazine.
Is that the British tabloid with all the topless models? I haven't noticed any topless models around here; but maybe my eyes are getting weak.
If talk therapy were a drug the FDA would ban it for lack of efficacy (cf. e.g. all diet programs).
I'm not sure allowing psychologists to prescribe would not just worsen the situation, and it puzzles me to see this being advocated as the answer. Why wouldn't psychologists just go the way of psychiatrists in the cheesey prescribing behavioral tendency? They would of course. Go where the money is. Psychologists do less damage simply because they cannot administer things that disable brain chemistry. And occasionally you'll find one or two who actually do some good, and the patient is able to really get something out of it. It all depends on the patient, of course.
Well, not really all. There have been studies done that show that in environments with low expressed emotion, there is less stress and fewer psychotic episodes in severely distressed people. High expressed emotion includes things like expecting science to fix people. And studies have been done at Auburn University that show that in families that believe in the medical model (biopsychiatric) of mental illness, they want to spend less time with the supposedly mentally ill person than families (and friends) who believe in the psychosocial model.
Steven-
I realize you were quoting the expert in the story. I wasn't disputing your comments, I was disagreeing with the doctor who was quoted. One doctor, one quote. Not the definitive truth on the mater.
I really like following your blog as the articles are so simple to read and follow. Excellent. Please keep up the good work. Thanks.
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