Psychotherapy from the psychiatrist’s point of view

We really don’t even have a precise definition of what “psychotherapy” is, and CPT coding has defined it in terms of time spent in a session and reimbursements.

A 50-minute session gets coded as 90807 which stands for “45-50 minute psychotherapy session with medication management on an outpatient basis in a physician’s office.”   The frequency doesn’t matter, nor does the content of what transpires– at least not for the CPT codes.  But certainly, not everyone who comes for a 50 minute sessions is actually in a formal insight-oriented psychotherapy.  Good care involves listening to the patient before making decisions about medications, and seeing 4 patients an hour, lined up on a conveyor belt, hour after hour, regardless of the patient’s need to talk or the complexity of the case, is no way practice psychiatry (and I personally wouldn’t have the stamina).  Those who do it have bought in to an insurer’s idea of how the world should work.    In fact, very few psychiatrists in Maryland reported that they practice this way, even if the media would have you believe that this is the norm in psychiatry.

I like to think of psychotherapy as a process over time where the talking itself is part of what heals.  Certainly there is something about talking openly about things which may be troubling, embarrassing, or leave one feeling vulnerable, which is helpful, particularly in a setting deemed to be safe and free from negative judgment.  From the psychiatrist’s point of view, psychotherapy is about looking for patterns in thoughts, feelings, behaviors, or reactions, and bringing these patterns to the patient’s awareness in a way that may allow him to change.

Obviously, I think psychotherapy is important to psychiatry.  Please check out the other posts on Shrink Rap News and Shrink Rap Today for other takes on the issue

Dinah Miller is a psychiatrist who blogs at Shrink Rap and co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

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  • http://twitter.com/dr_aletta Elvira G Aletta, PhD

    While I appreciate what you say about psychotherapy, there is a lot more to being a good therapist and delivering good care using a talking therapy. Treatments such as cognitive behavioral therapy, dialectical behavioral therapy, and psychodynamic psychotherapy require years of education and supervised training to deliver effectively. A good friend can provide a non-judgemental ear. Only a good therapist, whether an MD, PhD or whatever, can deliver good psychotherapy.

  • http://twitter.com/dr_aletta Elvira G Aletta, PhD

    While I appreciate what you say about psychotherapy, there is a lot more to being a good therapist and delivering good care using a talking therapy. Treatments such as cognitive behavioral therapy, dialectical behavioral therapy, and psychodynamic psychotherapy require years of education and supervised training to deliver effectively. A good friend can provide a non-judgemental ear. Only a good therapist, whether an MD, PhD or whatever, can deliver good psychotherapy.

  • http://twitter.com/dr_aletta Elvira G Aletta, PhD

    I should add that I think it’s terrific that you, a psychiatrist, provide more for your patients than a ‘script. As you point out, there are more of you than the media would have people think. Psychiatrists like you are golden, nonetheless. 

  • http://twitter.com/dr_aletta Elvira G Aletta, PhD

    I should add that I think it’s terrific that you, a psychiatrist, provide more for your patients than a ‘script. As you point out, there are more of you than the media would have people think. Psychiatrists like you are golden, nonetheless. 

  • Matthew Mintz

    “Those who do it have bought in to an insurer’s idea of how the world should work.”
    This is not really a fair statement.  Your post clearly makes the case that psychotherapy should be part of psychiatry. However, in your practice, you take none of the major insurance carriers. “Very few psychiatrists in Maryland reported that they practice this way,” because very few Maryland psychiatrists similarly do not accept insurance.  Many patients are not able to or are not willing to pay out of pocket to see a psychiatrist, so they go with one of the few psychiatrists that accept their insurance.  Since insurance doesn’t really pay for an MD to do psychotherapy, few of the psychiatrists that take insurance do it. Though you may not have meant to, the above statement seems like a knock on any psychiatrist who has chosen to stay within the system and do the best they can.  It is the system that is the problem, not the psychiatrists.

    • ShrinkRap Blog

      It’s a very complicated issue.  The “majority of psychiatrists in Maryland don’t practice this way” I was referring to the fact that very few see four patients/hour every hour (my idea of conveyor belt psychiatry).  Most psychiatrists reported that they typically see 1-2 patients/hour, and most of the psychiatrists I know in private practice do Not participate in insurance networks, or do so on a limited basis (participate with a few, and otherwise work out-of-network).  Certainly, accepting insurance is the socially responsible thing to do–it allows people to access care at reasonable rates.  But it does allow insurance companies to dictate how care is reimbursed, and many doctors then feel pushed to maximize their incomes within the system to the detriment of good care.

        I really just wanted to point out that psychiatrists still do psychotherapy (at least most of the psychiatrists, some of the time) and that the view that the media gives, that psychiatrists no longer see patients for therapy, is not correct.  But for the record, I don’t believe that psychiatrists who don’t do psychotherapy can give good care seeing high patient volumes (meaning 4-6 patients an hour for many hours of the day), good medication management takes time, requires listening to the patient, and having time to partner with them.

  • Matthew Mintz

    “Those who do it have bought in to an insurer’s idea of how the world should work.”
    This is not really a fair statement.  Your post clearly makes the case that psychotherapy should be part of psychiatry. However, in your practice, you take none of the major insurance carriers. “Very few psychiatrists in Maryland reported that they practice this way,” because very few Maryland psychiatrists similarly do not accept insurance.  Many patients are not able to or are not willing to pay out of pocket to see a psychiatrist, so they go with one of the few psychiatrists that accept their insurance.  Since insurance doesn’t really pay for an MD to do psychotherapy, few of the psychiatrists that take insurance do it. Though you may not have meant to, the above statement seems like a knock on any psychiatrist who has chosen to stay within the system and do the best they can.  It is the system that is the problem, not the psychiatrists.

    • ShrinkRap Blog

      It’s a very complicated issue.  The “majority of psychiatrists in Maryland don’t practice this way” I was referring to the fact that very few see four patients/hour every hour (my idea of conveyor belt psychiatry).  Most psychiatrists reported that they typically see 1-2 patients/hour, and most of the psychiatrists I know in private practice do Not participate in insurance networks, or do so on a limited basis (participate with a few, and otherwise work out-of-network).  Certainly, accepting insurance is the socially responsible thing to do–it allows people to access care at reasonable rates.  But it does allow insurance companies to dictate how care is reimbursed, and many doctors then feel pushed to maximize their incomes within the system to the detriment of good care.

        I really just wanted to point out that psychiatrists still do psychotherapy (at least most of the psychiatrists, some of the time) and that the view that the media gives, that psychiatrists no longer see patients for therapy, is not correct.  But for the record, I don’t believe that psychiatrists who don’t do psychotherapy can give good care seeing high patient volumes (meaning 4-6 patients an hour for many hours of the day), good medication management takes time, requires listening to the patient, and having time to partner with them.

  • Taylor Graham

    I cannot emphasize enough how important access to a good psychologist/psychiatrist/social worker/whatever is for people. I was in a really bad place this past fall and winter and my pcp recommended trying an SSRI. I really did not want to do that as I like to take as few prescriptions as possible. She then suggested therapy, which I was open to. She gave me a list, but of course finding one that accepted my insurance and was taking new patients was a challenge. Only through posting here (and Dinah responding to that comment) was I able to finally find a couple therapists (PhD) in my insurance network and do some phone interviews. I have been seeing my psychologist since January and she has helped me change my life ways I never thought possible. I am so much happier, feel like I am living my life for myself for the first time ever, and sometimes I feel like I owe it all to her even though I know she has not done all these things, but guided and encouraged me. Good psychotherapy is PRICELESS.

  • Taylor Graham

    I cannot emphasize enough how important access to a good psychologist/psychiatrist/social worker/whatever is for people. I was in a really bad place this past fall and winter and my pcp recommended trying an SSRI. I really did not want to do that as I like to take as few prescriptions as possible. She then suggested therapy, which I was open to. She gave me a list, but of course finding one that accepted my insurance and was taking new patients was a challenge. Only through posting here (and Dinah responding to that comment) was I able to finally find a couple therapists (PhD) in my insurance network and do some phone interviews. I have been seeing my psychologist since January and she has helped me change my life ways I never thought possible. I am so much happier, feel like I am living my life for myself for the first time ever, and sometimes I feel like I owe it all to her even though I know she has not done all these things, but guided and encouraged me. Good psychotherapy is PRICELESS.

  • ShrinkRap Blog

    Oh, I liked being mentioned in this comment!  I’m glad you found someone who was so helpful to you.
    ~ Dinah

    • Taylor Graham

      Good! Thanks for the advice; it helped me keep looking when I wanted to give up.

  • Kaynaz Nasseri

    Awsome post …..Therapy is where that can happen. Psychotherapy provides the space that is uniquely your own, where you can feel safe, at ease, and free from judgment. Within a trusting relationship,psychotherapy provides the place and the means to express the concerns one carries.Kaynaz Nasseri’s psycho-therapy practice is built on a broad range of training and knowledge that allows her to address a wide variety of issues, some of which include relationships, mood, school concerns, life transitions, and other psychology issues. Her approach to psychotherapy and psychological assessment is warmly interactive, providing support, insight and useful feedback to help one resolve difficulties and achieve one’s goals.Kaynaz specializes in assessment, treatment, and therapy services for children, adolescents as well as adults with psychology issues or problems relating to psychology. She is a psycho-therapist experienced in helping clients determine and implement solutions for a wide range of psychology problems. In a comfortable and supportive atmosphere, Kaynaz offers a highly personalized approach to psychotherapy that is tailored to each of her clients’ individual needs to help attain the personal growth and goals they seek. Her approach to psychotherapy utilizes sensitivity and warmth to help patients struggling with depression, anxiety, relationship difficulties, family problems, life transition problems, and other psychology issues.