Sunday, March 6, 2011

Psychiatrists Abandon Talk Therapy

Change has come to psychiatry. Not just a minor tweaking in technique, but a sea change.

In the past psychiatrists used to practice talk therapy. Today, they write prescriptions.

Today the New York Times chronicles this change by profiling a psychiatrist named Dr. Donald Levin. Link here.

Dr. Levin used to offer his patients 45 minutes worth of talk therapy. Now he restricts them to the 15 minutes it takes him to conduct a brief checkup and write a refill prescription.

You might imagine that Dr. Levin changed his practice because he discovered a more effective way of treating his patients.

If you did, you would be wrong. Dr. Levin believes that he was forced to change, against his best medical judgment. He did it because he could make more money writing prescriptions.

Dr. Levin feels ashamed of what he is doing, which is reasonable, but he keeps on doing it. This tells us that he is not all that ashamed. In truth, he is so unashamed that he brags about his good fortune to the New York Times.

Of course, psychiatrists are mere pawns in the hands of insurance companies. These latter will no longer pay the rates that Dr. Levin wants to charge for 45 minute sessions, and, significantly, patients are refusing to pay out of pocket.

You do have to ask whether patients would be more willing to pay if they thought that they were getting value for their money.

On the other side, there are still a few New York psychiatrists who treat investment bankers, the Times reports, charge $600 an hour. Are these patients getting value for their money?

In fact, the Times ran a fascinating article about several of these psychiatrists and their gold-plated clientele. As it happens, I wrote several posts about these psychiatrists. Link here.

I concluded that these wealthy people were spending $600 for a mix of psychobabble and a few banalities worthy of a freshman philosophy class.

In truth, Dr. Levin also makes $600 an hour. He makes it by seeing 4 patients and charging $150 per session. This is far better than the $90 the insurance company will pay for a 45 minute talk therapy session.

You might be asking how the insurance companies arrive at these figures. For all I know it might reflect the results of the psychiatric research that shows medication working better than insight-oriented talk therapy.

Psychiatrists who complain about and demonize the insurance companies should consult their own profession’s research.

And what if insurance does not pay very much or very often for talk therapy because it has discovered that such therapy is largely ineffective?

As always, these issues are very easily muddled. The Times reports, correctly, that some forms of talk therapy work well with depression, but most of these involve cognitive behavioral treatment, which has very little, if anything, to do with what Freud called talk therapy.

As for what else works, reporter Gardiner Harris quotes one psychiatrist, Dr. Louisa Lance, who has the temerity to suggest that while medication is well and good, the human connection between patient and therapist is the most important therapeutic agent.

As it happens, there is nothing in science or psychiatry that will teach anyone how to develop such relationships. Psychiatrists are no better at it than anyone else.

Surely, Dr. Lance is right, but I would qualify her statement by adding that the old style talk therapy, the kind that goes back to Freud, precludes and even prohibits any real human connection between patient and therapist.

I am rambling a bit, because I find that Dr. Levin’s decision is difficult to defend on ethical grounds. After all, he did not change his practice because he wanted to help people to get better. He did it because he wanted to get rich.

By his own admission and his own metaphor, Dr. Levin sees himself as auto mechanic treating a broken down Volkswagen. Actually, he calls himself a good mechanic. Yet, he knows next to nothing about his patients and most often forgets their names.

What makes Dr. Levin continue to practice psychiatry? Nothing but greed. I am sorry to report that Dr. Levin does not even feign honorable motives. He is simply gaming the system.

But he wants you to empathize. He wants you to feel his pain. The kids need to go to college. He and his wife want to maintain the lifestyle that they have enjoyed for the past 40 years. He certainly does not want to go “backwards, moneywise” in his career. And besides, they lost money in the stock market.

So, it’s not really about helping people. It is all about treating people like broken down automobiles… all because Dr. Levin feels entitled to a certain lifestyle and income level.

While other people may be suffering the aftershocks of the  financial crisis, Dr. Levin feels that he should not have to join them, because he went to medical school.

How much is he making a year? $150 a quarter hour for 11 hours a day for 50 weeks a year comes out to something like: $1,650,000 minus expenses.

Are you feeling his pain yet?

Of course, Dr. Levin reports that his patients still like him, and they keep coming back for their refills. As for their general mental state, the article reports on one patient who seems to happy with his meds.

Beyond that, Dr. Levin is unhappy that he got out of the business of enhancing people's lives and into the business of maintaining their stability: “Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.”

Even with medication it does not seem to be all that easy a task. The Times reports a strange, but telling, fact: Dr. Levin receives around 20 urgent calls a day from patients in crisis.

You can place that within the context of a case load that comprises around 1200 patients. Still and all, if medication works so well, then you’d expect that so many of the doctor’s patients would not be in permanent crisis.

Then again, if your psychiatrist treats you like a Volkswagen, you too might suffer some psychological trauma. If your psychiatrist refuses to converse with you, you too might feel demoralized. And if your psychiatrist considers you to be a meal ticket, or a ticket to a posh retirement, then you might not feel confident in him, or confident in yourself for having chosen him.

Of course, we don’t really know how good Dr. Levin was as a talk therapist. Hopefully, readers of this blog have long since discovered that old fashioned talk therapy was not very effective to begin with.

As it happens, Dr. Levin’s wife is a licensed talk therapist. She does not practice talk therapy very much, because she spends a considerable amount of her time managing her husband’s highly lucrative practice. This does not feel like a vote of confidence in the powers of talk therapy.

For all we know, Dr. Levin is a better psychopharmacologist than he is a therapist. We do not know how well his patients did when Dr. Levin maintained strict analytic neutrality.

For all we know, the insurance companies who have driven psychiatrists out of the business of talk therapy may have done the world a favor.

But why did Dr. Levin allow himself to be interviewed for an article that does not make him out to be the most compassionate of healers. If I had to venture a guess, I would say that he trying to pressure the insurance companies, by making them look like the bad guys who are preventing the Dr. Levins of the world from providing better therapy.

If I had to take another guess, I would say that the real consequence of this publicity will be that insurance companies will soon start cutting reimbursement rates for quickie psychiatric consults.


Anonymous said...

i don't know what i would have done without talk therapy. i certainly would not be where i am today. it's crucial.

Anonymous said...

actually, as Bruce Wampold et al have shown, even the most average talk therapy works reliably better than medications. it is a myth that meds are better and cheaper.
However, whether it is meds or talk therapy, who the treater is matters more than what the treatment is.
some therapists, and some psychiatrists, simply achieve better outcomes than others, regardless of what the treatment is.
therapy does work. and in the end it may be cheaper and more durable than meds.
Dan B.

Anonymous said...

TO: All
RE: Welcome.... the world of THX1138.


[Today, Psychatrists take drugs seriously.]

Anonymous said...

P.S. Is this the 'ritalin' generation, come of age?

Are we ALL to be 'medicated' into submission?

Thoughts of Steve said...

It's actually quite simple -- medications work best in a crisis situation. As the patient moves more to a "baseline" state, cognitive behavioral techniques, "self-talk" and good mental hygiene (= reading, taking walks, making friends and so on) have a bigger impact.