Thursday, October 3, 2013

Psychotherapy Has No Image Problem - Psychotherapy Has a Managed Care Problem

There was an opinion piece in the New York Times a few days ago entitled "Psychotherapy's Image Problem".  The author goes on to suggest that despite empirical evidence of effectiveness and a recent study showing a patient preference for psychotherapy - it appears to be in decline.  He jumps to the conclusion that this is due to an image problem, namely that primary care physicians, insurers, and therapists are unaware of the empirical data.  That leads to a lack of referrals and for some therapists use of therapies that are not evidence based - further degrading the field.  He implicates Big Pharma in promoting the image of medications and that the evidence base for medication has been marketed better.  He implicates the American Psychiatric Association in promoting medications and suggests that the guidelines are biased against psychotherapies.

I am surprised how much discussion this post has received as though the contention of the author is accurate.  Psychotherapy has no image problem as evidenced by one the references he cites about the fact that most patients prefer it.  It wasn't that long ago that the famous psychotherapy journal Consumer Reports surveyed people and concluded that not only were psychotherapy services preferred, they were found as tremendously helpful by the majority of people who used them.  That study was not scientifically rigorous but certainly was effective from a public relations standpoint.

The idea that psychiatry is promoting drugs over psychotherapy seems erroneous to me.  The APA Guidelines certainly suggest psychotherapy as first line treatments and treatments that are part of selecting a therapeutic approach to the patient's problems.   Psychopharmacology is also covered and in many cases there are significant qualifications with the psychopharmacology. Further there are a number of psychiatrists who lecture around the country who are strong advocates for what are primarily psychotherapeutic approaches to significant disorders like borderline personality disorder and obsessive compulsive disorder.  Psychiatrists have also been leaders in the field of psychotherapy of severe psychiatric disorders and have been actively involved in that field for decades.   Even psychopharmacology seminars include decision points for psychotherapy either as an alternate modality to pharmacological approaches or a complementary one.  What is omitted from the arguments against psychiatry is that many payers do not reimburse psychiatrists for doing psychotherapy.

The author's action plan to politically promote the idea that psychotherapy is evidence based and deserves more utilization is doomed to fail because the premises of his argument are inaccurate.  There is no image problem based on psychiatry - if anything the image is enhanced.  There is definitely a lack of knowledge about psychotherapy by primary care physicians and it is likely that is a permanent deficit.  Primary care physicians don't have the time, energy, or inclination to learn about psychotherapy.  In many cases they have therapists in their clinic and just refer any potential mental health problems to those therapists.  In other cases, the health plan that primary care physicians work for has an algorithm that tells them to give the patient a 2 minute depression rating scale and prescribe them an antidepressant or an anxiolytic.

And that is the real problem here.  Psychotherapists just like psychiatrists are completely marginalized by managed care and business tactics.  If you are a managed care company, why worry about insisting that therapists send you detailed treatment plans and notes every 5 visits for a maximum of 20 visits per year when you can just eliminate them and suggest that you are providing high quality services for depression and anxiety by following rating scale scores and having your primary care physicians prescribe antidepressants?.  The primary care physicians don't even have to worry if the diagnosis is accurate anymore.  The PHQ-9 score IS the diagnosis.  Managed care tactics have decimated psychiatric services and psychotherapy for the last 20 years.

It has nothing to do with the image of psychotherapy.  It has to do with big business and their friends in government rolling over professionals and claiming that they know more than those professionals.  If you really want evidence based - they can make up a lot of it.  Like the equation:

rating scale + antidepressants = quality

If I am right about the real cause of the decreased provision of psychotherapy, the best political strategy is to expose managed care and remember that current politicians and at least one federal agency are strong supporters of managed care.

George Dawson, MD, DFAPA

Brandon A. Guadiano.  Psychotherapy's Image Problem.  New York Times September 29, 2013.


  1. Well written article. It amazes me that some pretty bright psychologists and psychiatrists still believe there is a widespread stigma against psychotherapy. This may be true in small pockets of the country, but by an large psychotherapy is very mainstream and people often enjoy talking about their experiences in social context without embarrassment and even with a sense of pride that they are learning about themselves. I attribute this to cultural changes, especially among men. Tony Soprano did more to destigmatize psychotherapy than the APA did in its entire existence.

    I simply cannot figure out what APA is hoping for with their optimism about ACA. They've tied themselves to the railroad tracks hoping this will make the engineer stop and give them a free ride. I think when one is in academics or on salary for too long it makes you blind to economic reality.

    1. I think a lot of it flows from a lack of leadership and vision. You don't have to be a genius to figure out where integrated care with "new financing schemes" will end or the complete lack of science involved in "measurement based care". In the last 20 years there has been only one President of the APA that resisted managed care initiatives.

  2. I get peeved at the NYTimes for publishing what is basically advertising as an op-ed piece. Guadiano not only presents meds as undesirable, he also presents modes of psychotherapy other than the one he practices as undesirable.

  3. I think it is part of the general trend to criticize psychiatry from every possible angle and ignore the work that we all do on a daily basis. It goes far beyond this editorial. There are blogs written by psychiatrists that use the same broad brush. All psychiatrists are corrupted by drug company money. Psychiatry has foisted a flawed diagnostic manual on us to make money. Psychiatrists don't know what they are doing. Psychiatrists are doing med checks to make money. The list is never ending. I don't know about you but I've got about 10 shelves of psychotherapy texts, with an evidence base stretching back over 3 decades. A lot of that has been incorporated into my practice and it helps me treat patients and those patients get well. This whole idea that the average psychiatrist is a pill pusher is a convenient stereotype for political purposes that has nothing to do with reality. The other trend captured here is the polarization of research. It is quite easy to demonstrate with one meta-analysis or another that a treatment is superior or inferior to your favorite treatment. I could start pulling references right now to illustrate that. Very few people talk about the predictive capacity of meta-analyses and that fact that (on a good day) they might predict a clinical trials result 2/3 times.

  4. Are you still a member of APA? I gave up on them right after my residency. I see them as a pseudoscientific guild. Psychologists got fed up with their own APA years ago over the same issue and formed the Association for Psychological Science.

    Needless to say, I am not a member of AMA either.

  5. I am an APA and AMA member along with numerous other organizations. I don't think the APA qualifies as a guild because it is not politically successful enough to be a guild. The other association I had about that is - could you imagine the state of plumbing, electrical and general construction if all of those workers were managed by an entity that rationed their expertise to make buildings or said they could manage 50 jobs by looking at a construction checklist without ever going to the job site? Being a guild would not necessarily be a bad thing. The AMA and APA seem to be interested in rubber stamping whatever the government wants and have picked up on the "cost-effectiveness" rationing rhetoric.

    I like the educational stuff and at the DB level, the opportunity to talk and network with colleagues in the field.

  6. I'm not sure being an ineffective guild is a ringing endorsement!

    I am pretty meh on APAs CME stuff, as much of it is like PGY2 review. I just attended an advanced psychopharm course outside of APA that was far more useful. Stahl's psychopharm texts are infinitely more readable than the APA texts like Schatzberg.

    The biggest issue I have with APA is that it is run by hyperpolitical academics with no appreciation of the realities of private practice. I think they have been very destructive as exemplified by their endorsement of big government and managed care assembly line psychiatry. I simply refuse to go along. As far as networking, most psychologists I know consider it a plus that I am not an APA member and a DSM skeptic.

  7. I don't get it. If you guys are sooooo fed up with your field and know these guys are totally out-ethics, then why don't you do something about it? The public see what the APA wants them to see and believe. Can't the remaining doctors who do not agree with what the APA is pushing, call them out and make them responsible for
    their actions? If you think it is bad being a part of the APA, then you should try living in a world where they think they are GOD and getting away with it.

  8. Anon,

    The APA is too politically inept to either think they are God or get away with it. Practically everything you read in the media about the power of the APA is nonsense. Just this year the APA has demonstrated that it had to cooperate with the federal health plan and also a model of care that does not involve psychiatrists seeing patients. No organization of physicians with any kind of power would ever do that.
    When I think about God like entities in the health care system only two come to mind – the government and the managed care industry. To give a few examples of what I mean – both the government and the managed care industry control access to psychiatrists. You will not be able to see them in your insurance plan if they are not covered or part of the network. If you need hospital care, outpatient psychotherapy or expensive medications that all depends on your insurance company and they can think up reasons to deny you psychiatric care.

    That is really the point of the post. The reporter like most people comes up with totally erroneous reasons about why it is hard to see a psychotherapist. He omits the biggest (by far ) reason – managed care companies and their partners in the government don’t want you to see a psychotherapist no matter how useful it might be. The same two parties also want to see people put on antidepressants based on rating scale scores as soon as possible.

    That is where the real power in mental health care is. They control the purse strings and the government lets them do what they want.