Do We Really Need Psychiatrists to Do Therapy?

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In a front page story headlined “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy,” the New York Times Saturday bemoaned the fact that most psychiatrists now focus on prescribing medications, not practicing psychotherapy.

Writes Gardiner Harris:

Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.

Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Harris makes this sound like a disaster. But who says it even makes sense to get talk therapy from an M.D.? As Gardiner notes in his article, therapy done by psychologists and social workers is not only less expensive, but equally effective.

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And, in an age of rising health care costs, it seems rather odd to romanticize the plight of pricey psychiatrists who “miss the mystery and intrigue of psychotherapy,” as Levin puts it. Later in the article, the doctor admits that he could practice therapy if he wanted to, but, “Nobody wants to go backwards, moneywise, in their career. Would you?”

Implicit throughout the story is a sense of loss, contained in the idea that talk therapy is better and more “authentic” than medication. But research shows that they work about equally well for most cases of depression. For the most severe cases, a combination of drugs and talk has been shown to be best — however, that doesn’t mean that the psychotherapy part of treatment requires an M.D.

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Dual care needs coordination with a social worker or psychologist — which may be hard to accomplish in the brief sessions currently provided by psychiatrists — but is hardly a good argument for requiring an M.D. for the therapy portion.

And why is it only within the realm of psychiatry that we feel that “easy,” convenient treatment is somehow worse? When medications or surgical techniques are introduced that make physical healing quicker and less painful, they are praised as miracles. Recover from depression with a pill, however, and you are seen as having taken “the easy way out,” or avoiding the “hard work” of therapy.

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Patients certainly need options and there are many cases in which talk is clearly superior to drugs. Care needs to be coordinated if medication and psychotherapy are both needed. But there’s no reason that I can see for the talk to be provided by an expensive M.D. — or for drugs to be seen as a lesser, lazier option.

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