Thursday, June 3, 2010

Mass General Hospital Provides Great Therapy Training, But....

This is a brief note to respond to some understandable misinterpretations of both my New York Times Magazine article and my book, Unhinged.

My psychotherapy training at Mass General Hospital was excellent. As two young faculty members wrote in a recent letter to the Times in response to my article, MGH's psychiatry residency includes "
three years of intensive, individual supervision in psychotherapy." That was true in the early 1990s as well. I saw a lot of therapy patients and received great supervision from such skilled psychiatrists/psychotherapists as Robert Abernathy, Paul Hamburg, Chris Gordon, and many others. Not to mention superlative psychopharmacology supervision from such consummate clinicians as Andrew Nierenberg and Carey Gross.

I also agree with Drs. Roffman and Levy (the authors of the Times letter) that psychiatry residencies throughout the country are doing a great job of ensuring that psychotherapy training remains a central part of the programs. For many years, the American Board of Psychiatry and Neurology has published a list of "core competencies" required of psychiatrists. These have always included psychotherapy. According to the latest version, all psychiatrists should be able to "conduct a range of individual, group, and family therapies using standard, accepted models, and to integrate these psychotherapies in multi-modal treatment, including biological and sociocultural interventions." Furthermore, in 2001, the Council in charge of all graduate medical education (the ACGME) instituted a specific requirement that all psychiatric residencies teach cognitive behavioral therapy, and by 2006, 90% of residencies had complied.

And yet, notwithstanding these laudable intentions and curricular changes, psychotherapy by psychiatrists declined sharply from 1997 (when 44% of all psychiatry visits included psychotherapy) to 2005 (when only 29% of such visits included therapy.) This is because great training
during residency is necessary but not sufficient to bring therapy back to psychiatry. Once residents graduate, they have loans to pay off and they follow the money, and the money is found in short medication visits. And as with any complex skill, becoming an excellent therapist requires years and years of practice, most of it after residency.

One can always blame insurance companies for this state of affairs, but insurance companies reimburse more highly for med visits not because they are out to degrade mental health treatment, but because they believe they get more bang for the buck with meds. Based on the typical 6 to 8 week clinical trials, medications work as well as therapy for most conditions, and better for some. But studies are increasingly showing that--at least for non-psychotic disorders-- specific therapies work better than medication at preventing relapse over one or two years of follow up (see this study, for example). Good studies of therapy are hard to find, because drug companies are rarely willing to fund them. But I predict that as the evidence base for the long term efficacy of therapy expands, insurance reimbursement rates will improve as well.

In the meantime, however, my crystal ball reveals no impending great shift among psychiatry graduates toward therapy, no matter how many therapy supervisors residents are exposed to.

Bottom line: Psychiatry residencies do what they can to teach therapy skills, but the dominant culture among practicing psychiatrists remains medication-based, for a number of interwoven reasons including pharmaceutical marketing, insurance reimbursements, and the desire to be as "biomedical" as other doctors.


pacificpsych said...

I think you're absolutely correct.

An important study about psychotherapy's effectiveness:

Anonymous said...

Riddle me this: How many presentations on psychotherapy were given at the recent APA meetings in New Orleans? And how many such presentations were delivered by psychiatrists as principal authors/presenters? And what was the ratio between therapy and medication or biological intervention papers/posters presented at APA? Just curious.

Anonymous said...

And... how often are articles published in the American Journal of Psychiatry or Archives of General Psychiatry on psychotherapy? Once in a blue moon? You can spin this issue all you want but it is utter nonsense to suggest that psychiatric training in America values and embraces psychotherapy.

Joseph P. Arpaia, MD said...


From what I have seen I have to disagree with some of what you state here.

I have to be brief now, but if I have time I'll put more details up.

My beef is with your statement "insurance companies reimburse more highly for med visits not because they are out to degrade mental health treatment, but because they believe they get more bang for the buck with meds."

From what I have seen insurance company reimbursement has little to do with cost-effectiveness and is mostly related to political maneuvering. See this recent post on the Health Care Renewal blog for details,

This has lead to many of the serious problems we are seeing in health care.


moviedoc said...

I offer another explanation of the relatively low third party reimbursement: Look at your own statement, "I saw a lot of therapy patients." Third party payers would rather hear you say, "I successfully treated a lot of mentally ill patients with psychotherapy." But far too many "patients" still stay "in therapy" for years, purportedly treated for trumped up diagnoses like Major Depression, but really because they like the process or they want help with "issues" like relationship problems. Few psychotherapists, regardless of the letters behind their names, have the integrity to refuse to submit claims for such "treatment" when faced with a person who wants help. And few of those people wanting help value that help sufficiently to pay out of pocket fees comparable to what physicians (whether psychiatrists, PCP's or internists) can collect for medication management.

gewisn said...

"the dominant culture among practicing psychiatrists remains medication-based"
The answer is: "the dominant culture remains medication-based." Almost no patient or PCP really reserves medications for HTN, Hyperlipids, obesity, headaches, etc., etc, until AFTER diet/exercise/meditation/lifestyle changes have all failed truly sufficient efforts. Why would anyone expect psychiatric problems to be handled differently? Psychiatrists prescribe medications primarily because that is their expected role in this society. There is plenty of blame to go around to everyone involved - including patients and psychiatrists. None of us should oversimplify this to accomplish the personal agenda of assuaging guilt or to feel morally superior. Such oversimplification for the purpose of personal aggrandizement accomplishes nothing for the patients. Everyday, we all have to battle the temptation to take the easy way out in most everything we do (in professional and personal life). This is no exception - and I'm less guilty of doing it.

Instead of spending our time complaining about all the "bad" psychiatrists out there, let's spend our time reminding each other of all the ways we can battle the temptations to short-change our patients and encourage each other to do what's right instead of what's expedient.

Uma said...

I think every doctor who writes a prescription should take time to get to know the patient. The human touch has gone missing out of the medical profession.

Anonymous said...

As a therapist, I agree with many of the statements. They tried to put counseling codes in the DSM, since so many of the mental health issues are a mix of relationship problems both current and past and the interaction with a person's biological make-up and lifestyle. But, most therapists don't use them--since we don't have true parity in mental health, if someone is in severe depression due to the loss of a loved one, or loneliness etc. these likely would not be deemed "medical" per say--although the person is suffering and still sometimes resort to self-harm, self-destruction, or even suicide. Someone here commented about being in therapy for year, that may be true sometimes, but again, in practice most people are on medication for years and there are millions of children now who have been medicated since age 5 for a wide range of things, beyond just the wide use of ADHD medications.

I would like to see Psychiatrists do biometric testing, or order such tests done for basic things before medication regime's or shortly there after at least. Many patients with severe problems certainly have other physical ailments as well, due to obesity, horrible diets, diabetes, and the like.

Sadly, most patients could be in therapy and medicated for years and not realize they have tumors, cancer, hypothyroidism etc. I have found that most people can identify their 'presenting problems' fairly quickly, but on occasion I have seen clients whom have good relationships, no past trauma's but suffering from severe depression without concurrent Automatic negative thoughts or other things they ruminate upon--but I struggle to get them referred for biometric tests. I suppose it's b/c they are M.A. clients and I have years of experience watching no testing get done, usually when I start advocating for clients that are becoming obese and showing severe symptoms for high doses of atypicals (again for clients not even deemed bi-polar etc, but rather R.A.D. etc). The scary thing is that research shows that your best chance of being diagnosed mentally ill and medicated is not if both your parents had SMI, but rather if you are a foster child. In 2005 a large studied showed that nearly 60% of all foster children in America are medicated.

I'm fine with well trained Psychiatrists doing therapy, but I would rather them use their medical knowledge and find out if they are hypoglycemic, what lifestyle factors contribute to their mental state such as lack of nutrition and the like.

For those in therapy without much progress for extended time, it's time for a re-evaluation with further biometric testing, medication, and either a break in therapy, or a new therapist, I for one don't like when therapy become's 'spinning wheels' and would rather not demean my profession by trying to string anyone along for the fairly paltry amount of money I earn anyway. I'm sure many psychiatrists feel the same way about the few MD's that are milking the system and acting unethically and making up false data merely to get rich, but we do live in a very materialistic society, greed is good in the minds of many.

John Nardo MD said...

I left Emory as Director of Residency Training in 1967, a few years before Dr. Nemeroff arrived. We'd gotten a new Chairman who moved on quickly, but the changes you present here were in the wind, and there was no place for a Residency Director who was also an Analyst/Psychotherapist. The psychotherapy program continued, even at Emory, but it was an aside. I expect it was an aside at other places too.

Our residents are really not being trained for the breadth of our discipline any more. In Atlanta, we're beginning to offer psychotherapy training in the analytic institute, and residents are prominent among the takers. They seem to know that they're being short changed.

I appreciate your sticking with this issue. It's long overdue...