What is Psychotherapy and What’s in A Code?

 

After a recent discussion about psychotherapy done in psychiatric treatment – I decided to write this post in order to capture the complexity of some of these sessions. I hope that this post serves multiple purposes including a demonstration about how business management affects psychiatric care and the range of services that people receive in psychiatric follow up appointments. The audience for this post will be people seeking psychiatric services, psychiatrists of all orientations, and anyone interested in quality psychiatric care.

The fundamental unit of psychiatric care comes down to what tasks need to be completed in a set time frame and there are a lot of variables. Rather than list those variables – it is probably easier to describe a limited or rationed task scenario and compare that to an abundant task scenario.  Most peoples experience with psychiatrists in the US will fall somewhere between the extremes.  From a scheduling perspective there are no assurances that what a patient needs on a particular day will be the session they are scheduled for.

In the most limited care, the patient is seen for follow up or “medication management”.  These visits developed as part of a coding scheme that suggested that psychiatrists could see patients for very brief (5’-15’) periods of time with an exclusive focus on the medication a person was taking, whether it was effective, and whether they were experiencing any side effects. To speed up the process, many clinics have templates that are rapid checklists of symptoms and side effects.  In some cases, as the patient speaks the psychiatrist is checking off items on the list so that at the end of the session, a couple of sentences can be typed and the note is complete. Depending on the setting, additional information that might be acquired in the rooming procedure during a standard medical appointment (like pulse and blood pressure) may or may not be collected. Before psychiatrists started using standard billing codes like the rest of medicine, there were codes that assumed this limited care could be completed in anywhere from 5’-15’.  As far as I know - no other medical specialty had codes that were as restrictive.  In some clinics patients would be seen for that period of time every 6 months.  That duration and frequency of medication focused visits might work well for some people, but there is an understandable concern about quality when it is applied on a population wide basis. That concern is amplified where patients have more medical and psychiatric complexity (high risk for medical or psychiatric complications).   

At the other extreme, a psychiatrist may see a patient for 30-60 minutes in follow-up. A psychiatrist who typically sees people for 30 minutes would review the efficacy and side effects of any psychiatric medication.  They also may cover more medical or neurological considerations and following another condition like the patient’s problem with hypertension, diabetes, or neurological conditions.  In the remaining time, there is a detailed discussion with the patient.  In the case of a 50'- 60’ appointment, the psychiatrist is most certainly providing psychotherapy in addition to medical treatment. They may be providing psychotherapy exclusively.  Standard billing codes can be used, there are also psychotherapy add on codes and a separate psychotherapy code. Over the years, a lot has been written about the financial incentive for seeing many more of the briefer visits per hour than longer sessions involving psychotherapy. Practice setting tends to be the overriding factor.  If you are employed in a clinic or hospital, there is some administrator telling you how many people you need to see in a day.  That number is referred to as physician productivity.

There is a lot of confusion about what constitutes psychotherapy. At its core, psychotherapy is a teaching experience where the therapist attempts to assist the patient in solving problems that complicate their psychiatric disorder or affect their ability to adapt to life situations.  That can cover a lot of ground including inflexible thought patterns, stressful relationships and current or past stressors. It can also be a very focal problem that might require some directive education like sleep hygiene, diet, and exercise modifications. The teaching needs to occur in the context of a relationship that is both empathic and collaborative.  That collaboration is often referred to as the therapeutic alliance to indicate that the physician/therapist and the patient are aligned to focus on and resolve a mutually agreed upon set of problems. The common view of psychotherapy is that it needs to be long in duration and that the therapist “analyzes” the patient during that time. That description comes from psychoanalytic therapy that is a very specific therapy done be relatively few psychiatrists and it does not represent most of the brief psychotherapy done in treatment sessions.

There has not been a lot of study of psychotherapy in psychiatry in the real world. The best single study by Mojtabai and Olfson (1) and it is the most often quoted.  The most notorious quote is:

“ …..third-party reimbursement for one 45- to 50-minute outpatient psychotherapy session is 40.9% less than reimbursement for three 15-minute medication management visits.”

That led to the expected provocative articles about psychiatrists abandoning psychotherapy or being too motivated by money.  The reality of what it takes to keep a practice open in the face of paltry reimbursement was never mentioned. Some articles got so extreme they called for the end of psychiatry, replacing the greedy psychiatrists with therapists trained to prescribe. The authors of the article provide a much more balanced perspective including their opinion that many psychiatrists were still providing some kind of therapy and that their measures of what constituted therapy may have undercounted the therapy provided.

Polarized viewpoints of what actually occurs when a psychiatrist sees a patient probably described very little of what happens in real life sessions. From working in various settings with psychiatrists of three generations, there are many styles of practice and how psychotherapy is integrated – even into very brief sessions.  I was fortunate enough to work with a psychiatrist who ran a clozapine clinic and a separate clinic for long-acting injectable medications.  Both clinics were probably the largest in the state. He would typically see people in 20’-30’ appointments based on the complexity of the care they needed on that particular day. He was an expert in psychopharmacology and medicine as it applied to that patient population. But more than that he was empathic and knew the relevant life details of all of his patients. There was obviously a high degree of patient satisfaction and engagement in treatment.  One of the obvious markers of his success was patient interest in this physician after he made a career change.  His former patients would approach me in the hallway and ask me how he was doing or if I had heard from him. They would talk about him in the most positive terms. I don't recall seeing that happen with any other psychiatrist who moved on.

Papers on the minimum time needed to provide a psychotherapeutic encounter have been written for the past 40 years now. With the advent of managed care – many of them emphasize how the rationing aspect has reduced the time for both verbal and medical interventions. The latest guidelines for residency training emphasize the need to learn psychotherapy but beyond advanced interviewing techniques cognitive behavioral therapy or CBT seems to be the predominate paradigm – even though residents are still exposed to a variety of paradigms from their supervisors and mentors. 

The best single paper I have found that describes the psychotherapeutic aspect of medical treatment within the confines of a “medication management” session and its considerable constraints was written in 2018 (2).  The authors argue for the need for a human-to-human connection consistent with the existential orientation in psychiatry in order for treatment with medications to work.  The main features described are empathic listening and alliance building. One of the primary ways they are realized in the sessions is a focus on the patients own description of the problems or progress. 

As I read through this paper, I realized that I had been conducting outpatient visits in this manner over the course of my career but that nobody had previously described it in these terms or suggested why it had been so successful.  But even as I read this brief paper – I realized that the description was incomplete. It did not describe the many active psychotherapeutic interventions that I had used over the years.  I learned most of them as supportive psychotherapy in residency and they include interventions that would now be described as behavior therapy, cognitive behavioral therapy, and brief psychodynamic therapy and they all happened in the constraints of brief sessions that were generally 20-30 minutes long – in addition to whatever I needed to cover about the medications and other medical conditions.

These 20’-30’ sessions are currently No Man’s Land in the field of psychiatry. It is easy to extremely pessimistic about them.  As I previously noted they can be a political football – since any bias can be projected onto them. That is probably why there has been so little research in the area. It is as if the managed care and CMS template for these codes is an inescapable reality. Everything on the template is all that occurs in one of these sessions. I would propose a thought experiment to counter. If you are a psychiatrist seeing patients in these sessions and billing these codes – do you cover more information than what is in the bullet points for these sessions? Is the patient predictable from session to session – is more lengthy clarification needed? Are there any sessions where the entire session has very little to do with medications?  Are there any sessions dedicated to crisis intervention and only verbal interactions about that crisis? Do you see family members during these sessions and discuss their concerns? When you assess whether a person is experiencing suicidal thoughts do you know how to discuss them in a therapeutic manner?  If the answer to any of these questions is yes – it is highly likely that some form of psychotherapy is happening – even if you do not consciously pull up a psychotherapy technique that you learned and used in the past.  That psychotherapy happens whether you decide to record it on a template or not.

I think this area requires a lot more study. The information transfer between two people that can occur in 20’-30’ minutes is vast – even if it is semi-structured. The first step is determining what really happens in these brief sessions.  If anyone does that study, I think we will find out that the treatment that happens is much more than medication management.

 George Dawson, MD, DFAPA

 

References:

1:  Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008 Aug;65(8):962-70. doi: 10.1001/archpsyc.65.8.962.

2:  Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check". J Clin Psychiatry. 2018 Apr 24;79(4):18ac12177. doi: 10.4088/JCP.18ac12177.

Graphics Credit:

Photo by Eduardo Colon, MD

 

Existential Psychopharmacology And Much More

 

 

I offered an opinion on existential psychopharmacology recently and after completing those three tweets - decided that a more comprehensive look at this issue was in order. Psychiatrists have been debating the extent of what can be done in time-limited sessions for at least 25 years now. Those debates basically come down to what the government and businesses allow psychiatrists to do. About 25 years ago there was a billing and coding scheme that suggested that psychiatrists could do a few things including a comprehensive evaluation, follow-up visits, follow-up visits with psychotherapy, and family therapy.  Eventually the follow-up visits without psychotherapy are broken down into “medication management” visits and very brief medication management visits. If you happen to work as an employee that might mean you had to see four or five people an hour and do the necessary documentation and billing. There were bitter debates about whether that was a long enough period of time to see someone. Because these designations all trickled down from the government and the business world they had very little to do with whether or not a psychiatrist could provide services that they thought were needed in those time frames. There some articles about how psychiatrists are just focused on medications and “no longer did psychotherapy”. There were counter arguments by psychiatrists and community mental health centers saying that they could provide adequate services in those time frames for a lot of people. The politics escalated the point that psychiatrists were being stereotyped as specialists who are only interested in prescribing medications.

Any critical thinker could question the idea of “prescription only” psychiatry. Looking at a few common scenarios illustrates why that is not possible or defensible irrespective of the fact that psychiatrists are trained to provide comprehensive mental health services. A common example encountered in clinical practice is the crisis situation.  The psychiatrist is treating a patient who they have been seeing for any length of time who suddenly experiences a crisis in their life usually due to an overwhelming loss or stressor. The appointment is no longer focused on the long-term treatment and needs to refocus acutely on the crisis. The crisis generally affects the evaluation and treatment of the long-term problem and I have had many patients state that explicitly at the beginning of those appointments. Medications can be prescribed for crises but in general the best approach is psychotherapy.  Staying with a rigid approach to the original problem is not only ineffective but it harms the therapeutic alliance between the psychiatrist and the patient. That alliance is built on the patient knowing that they are being heard and understood by the psychiatrist. Ignoring a new crisis fails that test.

Another common example about why “prescription only” psychiatry fails is problems that need to be discussed rather than treated medically. These vary from comprehensive analyses of various medical problems and how they fit into the psychiatric formulation to stressors and social problems. In many cases the approach is educational.  Common examples there would include recommendations on sleep, diet, and exercise where they apply. But the examples include supportive psychotherapy for interpersonal conflicts, maladaptive problem-solving, and any clear sequence of behavior that the patient has questions about that can benefit from additional discussion.

It doesn’t take too much consideration to understand that psychiatrists need to talk with their patients in great depth in order to establish a treatment relationship that works.  That is not to say that there are suboptimal practices at either end.  I have certainly talked with people who told me that their last doctor always seemed poised over a prescription pad and would only talk about medications. There are some mass prescribing practices in primary care that depend on checklist descriptions of symptoms for a diagnosis and then that diagnosis for a well-defined list of prescriptions. There are also patients who tell me that they were seeing a psychiatrist who was psychotherapy focused and very reluctant to consider a medication.  Eventually they did get someone to prescribe a medication that worked and they decided to terminate with that psychiatrist for not presenting medication alternatives to them.  Psychiatric practice is all about a balanced presentation of the diagnostic formulation and ways to address it and that always includes a dialogue with the patient that communicated both information and understanding.

 

Case Example:

I am working in a large trauma center on weekend call and have seen a number of admissions to the acute care unit.  I get a call to the Coronary Care Unit about a recent admission who is tearful and depressed. She was admitted to rule out a myocardial infarction and that was done but the fellow is concerned about discharging her without treatment for depression.

I interview the patient and she is definitely depressed and tearful. I learn that she has recently retired and is having some difficulty finding meaning in her life.  She was previously the CEO of a large company and her day was scheduled for years.  It was so scheduled that she needed an assistant and was in constant contact with her.  She has never seen a psychiatrist or psychotherapist before and never been treated for depression. She has two adult children and did not have postpartum depression associated with either pregnancy.  She is generally healthy and physically active.  Her husband has noticed that she is less interested in some of their mutual activities – tennis and travelling.

 A stereotypical approach to this problem of going down the diagnostic criteria for depression may not be the best one. When I am talking to a patient in this situation, I ask them to join me in a conference room for the interview and not in their CCU bed.  I introduce myself, explain why I was consulted and then ask the patient for their take on the situation.  The questions are always open-ended since I am interested in their unique experience of the problem. That is a technique I learned as a first year medical student and it was greatly expanded in psychiatry. Learning medicine involves trying to recognize certain patterns in what the patient is saying and then honing in for more specific details. Psychiatry is a little more complicated.  It involves recognizing the typical disease patterns (eg. stroke), the patterns specific to psychiatry (eg. aphasia versus formal thought disorder), and the best therapeutic way to talk with the patient (loss, role transition, problems associated with stroke, aphasia). The initial two elements of that pattern recognition are fairly straightforward but intense aspects of medical and psychiatric training. The third is not and it has been a topic that has been politicized over the years to the point that it has become confusing for both psychiatric residents and practicing psychiatrists.

The best way to conceptualize therapeutic discussions is to see it as an extension of interviewing and psychotherapy training. There is always plenty of hostility associated with the idea that psychiatrists might be doing psychotherapy with patients while they are discussing medications and medical treatment.  There should not be.  I have already illustrated in this post why it is impossible to function as a psychiatrist without psychotherapeutic discussions. The psychiatrists who I know who were highly regarded by patients approached all patient encounters this way.  They expected there was going to be a discussion with the patient that had nothing to do with their medications, but that was essential in some way to the patient’s wellbeing.  How exactly does that happen?

The basics start with those initial interviewing skills.  In psychiatry, an emphasis on empathy, boundaries, and therapeutic neutrality adds a lot to those skills.  Talking to hundreds of patients and discussing those experiences with supervisors adds even more.  I can recall for example, listening to a supervisor talk about how to directly express caring for the patient (“I am really concerned about your ability to take care of yourself”) and operationalizing that for the patient to assure their survival.  I recall seeing another one of my supervisors telling a patient who was sobbing uncontrollably to “snap out of it” (in a nice way) in order to proceed with identifying the patient’s problems. When I saw that happen it was shocking for a trainee, but watching the interview it was clear that was a necessary skill.

An additional level of skill building occurs with one-to-one psychotherapy with patients and the corresponding 1:1 supervision by staff clinicians. In my case, I was supervised based on direct observation, audio tapes, video tapes, and process notes – 3 ongoing cases/week for three years. Those supervisors were also a rich source of texts and papers on psychotherapy technique. As I was starting psychotherapy training I read texts by Grinker, Arieti, Sullivan, Yalom, Beck, Klerman and Weismann, Basch, Werman, Dewald and others.  I attended an APA seminar by Kernberg and read his research.  I attended an APA seminar by David Burns and read his book.  I read the competing approach by Kohut and read the “Two Analyses of Mr. Z” and several other papers.  I was exposed to Lorna Smith Benjamin’s Structural Analysis of Social Behavior (SASB) and Viederman’s  psychodynamic life narrative.  I remember thinking of Viederman’s paradigm as I interviewed a young patient and realizing that she was describing neuropsychiatric symptoms consistent with complex partial seizures and having to change the paradigm and refocus the interview.  The ability to do that is all part of the complexity of psychiatric treatment.

Getting back to my clinical example, we discussed the patient’s transition into retirement as being the most significant factor that eventually led to more depression, panic attacks, and admission to a coronary care unit.  With that as a major focus of the interview the cardiologist’s questions about acute suicide risk, transfer to a psychiatry unit and medical treatment could all be addressed. The recommended treatment was psychotherapy rather than a medication.  The Cardiology fellow was still making rounds when I finished.  I talked with her about the existential aspects of the patient’s crisis.  Luckily the fellow was a creative writing and philosophy major and knew where I was coming from. The discharge proceeded without a hitch and the patient was clearly improved when she left.

What I am describing is essentially a supportive psychotherapy approach.  I notice the themes that various psychotherapies were designed to address and test them out with the assistance of the patient.  Do they seem to be relevant to the patient or not? Most importantly what can be said in that context that will be the most useful to the patient? That can vary from education about the therapy and the theory, to a clarification tying various events and reactions together, to an interpretation based on the developmental history discussed over the course of the interview.  Once that has been done and documented in an initial assessment it continues to evolve over the course of treatment and sometimes beyond.  I have had people come back years later to discuss additional developments – all in the 30-minute interview.  When you have 30 minutes to provide comprehensive psychiatric treatment – it can be done.   

For the person interested in existential psychopharmacology, Ghamei, Glick and Ellison have written about it as a “humanistic approach to the med check” (1).  In this article the authors emphasize the need for human connectedness and how it is necessary for psychopharmacology.  It basically emphasizes recognition of the individual and personalized treatment rather than seeing people as cross sections of symptoms.  I could not agree with the authors more and have outlined common areas of discussion that I try to cover in psychiatric visits. They discuss pejoratives of the 15 minute “med check” that focus almost exclusively on target symptoms and medications for this target symptoms.  I agree that it is suboptimal care but I also cannot forget where it came from.  It is a product of the government and the health care business community. Historically, there is no psychiatrist who stood out for saying: “From now on let’s see all of our patients for 10-15 minutes and pretend that only changing their medications is effective psychiatric care”.  There were definitely business administrators who said: “If you want to get paid, we want you to see this clinic full of patients every 15 minutes.”  Purely medication-based treatment is not really psychiatric treatment and it continues today as collaborative care. In some of the original collaborative care models – the unique experience of the patient is completely ignored.  All patients complete the same rating forms for anxiety and depression and decisions are made on that basis.  The patient’s conscious experience is collapsed into an aggregate number and a rating on the subscale of suicidal thinking. The models are at the opposite end of the spectrum from personalized care and are heavily promoted by managed care companies and governments who consider some of these aggregate measures to be “quality measures”.  I attended a meeting two years ago, where people were trying to use tens of thousands of these rating scale reports to develop an artificial intelligence approach to predicting suicide for these numbers. Human consciousness is not that simple.  

I know that many will see a 30 minutes appointment with a psychiatrist as a luxury or “too much expense”. In fact, it is a starting point. Once treatment proceeds, every aspect of treatment including frequency and intensity can be discussed in sessions.  One of the most well-liked psychiatrists (by his patients) that I have known, had several large clinics where he typically saw most people for 20 minutes, but 30 minutes when he needed to. Over the years he knew the several hundred people in these clinics very well and his patients did very well.

This method is the outline of what I do in clinic every day, what I did on acute care inpatient units for 22 years, and what I did in a community mental health center for the first three years of my career.  One of the reasons for writing this blog is not to suggest that I am the standard to measure everyone else by.  I write this blog because I know that almost every psychiatrist including my supervisors and professors and my colleagues practice this way. 

I just figured out a way to describe it.

George Dawson, MD, DFAPA

 

References:

1:  Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check". J Clin Psychiatry. 2018;79(4):18ac12177. Published 2018 Apr 24. doi:10.4088/JCP.18ac12177 (free full text)

 

Addendum 1:

I was tempted to come up with a catchy name to encompass my approach to medical treatment and psychotherapy. I can see why the authors like the term existential.   

Addendum 2:

I don’t want to give the impression that my psychotherapy education ended in residency.  It is an ongoing process and I am always open to new techniques to help my patients.  The same way I study the medical conditions of my patients and make sure I completely understand the potential complications for psychiatric care.

Addendum 3:

I hope to come up with an additional post of the supportive psychotherapy techniques that I have found useful over the years and how I see that field evolving.