Is Talk Therapy Dead?
Remember when your psychiatrist would actually talk to you and provide therapy before handing out a script for medication? Yeah me neither. Yet back in the heyday of psychotherapy, it was a psychiatrist who usually conducted this type of therapy. But those times are long over. In a provocative article published in early March in the New York Times entitled, Talk Doesn’t Pay, so Psychiatry Turns Instead to Drug Therapy, author Gardiner Harris points to the changes in insurance reimbursement as the cause of the decline in psychiatrists who treat patients with psychotherapy. Talk therapy simply doesn’t pay. What does pay? Most psychiatrists nowadays write prescriptions to earn their salary.
This trend towards promoting drug therapy as opposed to talk therapy began in the 1980’s if not sooner. I was a witness to it. When I was a teen I would wait in the waiting room for my mother, who suffers from schizophrenia, when she had an appointment with her psychiatrist. When she would emerge some thirty minutes later I would marvel at how a doctor could spend so little time with her when she had so many challenges to discuss. When I would ask if the doctor had helped her, my mother would show me her prescriptions for new medications. It soon became apparent that there was very little therapy going on. Instead there was an over reliance upon drugs to treat her mental illness. What I didn’t realize then was that her thirty minute session with a psychiatrist was luxurious compared to what we are able to receive today.
Today the trend is for psychiatrists to provide brief consultation visits for 15-minutes or less to their patients. As the New York Times article points out, doctors make more money this way. Why spend 45-minutes with a patient earning less than $100 when you can make $150 dollars for seeing three patients for 15-minutes each for a medication consult? In essence, the insurance companies are dictating which treatment options you will likely receive if you visit a psychiatrist. In my opinion, it has produced a mental health system where doctor’s offices are becoming prescription mills. Volume is key so you are just one of many who go through the mental health revolving door, here is your prescription, now get out. It is of little wonder that so many of us find the system cold and impersonal. Who is taking the time to get to know us as people?
I don’t need to tell you about the inherent dangers in this prescription mill mentality which seems to dominate our mental health care system. For example how does a psychiatrist arrive at an accurate mental health diagnosis for a patient within a first initial visit? It seems incredible that a mental health diagnosis could be given in such a short time. An assessment leading to diagnosis used to take weeks or months but is now taking less than 45-minutes. Again, the insurance companies dictate that if the doctor wants to get paid, a diagnosis must be made quickly. This is leading many mental health professionals to make light of or disparage the integrity of an accurate diagnosis. I had one therapist tell me that he needed to put down something for my diagnosis so he gave me several choices and told me to pick one. It makes one wonder if there is any usefulness in a diagnosis other than as a way for the mental health practitioner to get insurance reimbursement.
The other danger to patients who are caught in our current mental health system is that medication is no longer seen as the last option before other non-prescription choices have been exhausted. Quite often medication is offered first, and talk therapy is suggested as a secondary treatment if at all. This is despite the evidence which shows that many patients respond to talk therapy and in a lot of cases find it more effective than medication treatment alone. A 2004 Consumer Reports survey of its readers concluded that: “Respondents who said their therapy was “mostly talk” and lasted at least 13 sessions had better outcomes than those whose therapy was “mostly medication.” The problem for many people is where to find a mental health practitioner who has the appropriate qualifications and expertise to provide good quality psychotherapy. And then there is the matter of how to pay for it. How many insurance plans (if you have insurance that is) will pay for 13 or more therapy sessions?
Some psychiatrists still offer psychotherapy to patients. But it will cost you. There is no guarantee what insurance will pick up and the tab can easily run from close to $200 a session and up. You don’t need to see a psychiatrist, however, to get therapy. Clinical psychologists and social workers can offer quality mental health services including talk therapy. But even these services have been greatly watered down due to how billing and insurance works. The emphasis is upon brief and time limited therapy often embracing behavioral goals as opposed to humanistic ones.
From a patient’s perspective it feels like I am being dissected. Go to this person for medication. But see this person if you want to talk about your emotions. Go here if you want to discuss how to change your behavior. No wonder we are confused and frustrated. As humans we are a complex mixture of biological, emotional, psychological, cognitive, and spiritual beings. Yet our health care system doesn’t look at us this way. We are parsed off to specialists who don’t ever take the time to see the whole picture because the system doesn’t allow it.
Is talk therapy dead? It is not dead yet but in my opinion it is dying. Many of you write in with questions about how to best treat your depression. I always mention talk therapy in most of my answers. But then I feel guilty because I know that for many of you, finding a mental health practitioner who provides good quality therapy at a price you can afford it like winning the lottery. It is a rare thing. But it shouldn’t be. There are no easy answers for those of us who suffer from a mental illness and need effective treatment. Many of us will fall through the cracks after being offered what amounts to band-aid solutions for a gaping wound. There has to be a better way.
What are your thoughts? Is there room in our current mental health system for talk therapy? Is this a treatment option which is on its way out due to the current emphasis on drug therapy to treat mental illness? Is there anything we can do as patients and advocates to change this trend? Let us know what you think. We greatly value your input.