The demise of talk therapy in psychiatry: New York Times article

[Dr. Richard Grossman]

Hi everybody,

There's an interesting article in today's (3/6/11) New York Times by Gardiner Harris:

"Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy"

http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?pagewanted=1&_r=1&nl=todaysheadlines&emc=tha3

I'd love to hear your comments.  (I'll share my thoughts later.)

Richard

[BonesMS]

In my limited view, he's become a general practitioner physician and can no longer call himself a psychiatrist.

Bones

[Twoapenny]

It's already like this in the UK and always has been, as far as I know.  Mental health problems are just patched up - basically meds are prescribed to keep people quiet and stop them being dangerous and that's the end of it.  There's no interest in the person's quality of life, whether or not they are meeting their full potential, whether or not they are happy.  There doesn't seem to be a terribly logical approach to prescribing either, they seem to just try stuff out and change it after a few months if it isn't working.

There's no focus on nutrition or exercise, both of which I think are vital to good mental health.  There's no opportunity to build up a trusting relationship with your doctor because you don't see them often enough or long enough (and that's bearing in mind you have to have a serious mental health problem to be referred to a psych; if it's bog standard depression then you see your GP and that's a five minute appointment).  There's often not even a consensus on a diagnosis.  When I was admitted to hospital the first time I saw four different doctors in four days and they each told me a different diagnosis.  I went to a private psych and got a different diagnosis again, which the NHS doc refused to accept but also wouldn't tell me why he didn't feel it was accurate.  Confusing and destabilising doesn't come close.

Talk therapy has been the only thing to help me long term.  Self help, in the form of diet and exercise I can do at home.  This board has been really useful.  But my T has basically been re-programming my brain.  She's been helping erase those old messages from my childhood and teaching me new, healthier ones.  She's taught me how to have boundaries, how to have confidence in my own thoughts and feelings.  She's taught me that it's okay to have emotions, even the 'bad' ones like hate, anger, jealousy and so on.  She's encouraged me to put myself first and taught me that I don't have to be perfect to be a good mum, I just need to keep my boy safe and love him, which is easy for me to do.  She's the only person in my life I've ever been able to truly trust; I've talked to her about things I've never spoken to anyone else about and probably never will.  She's allowed me to dump my abuse - the vile memories, the feelings of hurt, revulsion, the sense that it's all my fault and always will be - in her office and leave it there, so it doesn't pollute and permeate my home.  There isn't a tablet in the world that can do all of that.

Don't get me wrong, I believe meds have their place, and I know there have been times when tranquilisers where probably the only thing that stopped me from killing myself.  But I think they should be part of a much wider programme and the emphasis should be on them being used minimally as a way of supporting more deep seated and intensive life changes, rather than a quick and cost effective solution to something that's complex and, in so many cases, cureable without the need to be on medication for life.

I know I'm rambling on a bit and going off topic (sorry!) but here in the UK the thing I find best about going private is that you can pick and choose what you need and what you want to use.  On the NHS you have to basically prove to someone there's a problem before they refer you.  There's a certain criteria that must be reached before you progress through the system and a lot of fobbing off and passing the buck goes on.  I see a therapist and a homeopath regularly, and because I pay them I don't have to justify to them why I should be there and they follow my lead.  They spend a lot of time with me and know me really well.  My homeopath knows me far better than my GP ever would and my therapist knows me better than anyone else in the world.  So I feel that when the health care on offer is governed by money, rather than by what is best for the patient it leads to problems.  I have a degree of empowerment in my health care that I can't get if someone else is paying for it, because then I have to play by their rules rather than my own.

[sKePTiKal]

Will this de-certify the Ts that continue to do talk therapy? Invalidate the method?

Why is it that we're (globally, socially, politically) in an era where everyone wants to completely re-invent everything? What about the "evidence" of all the people who've been helped by this method? What are they - chopped liver? Accidental results?

And what happens when people develop a resistance threshold to drugs? Do we have to endure more Moammar Quadaffis, Charlie Sheens, Mel Gibsons, and Diane Bishops? Pharmaceuticals do have a point of diminishing effectiveness. "Better living through science" has proven to have some very unaddressable unintended results.

[SilverLining]

I think it's a very unfortunate trend.  I've been down the path of chemical therapy myself, along with my two siblings.  To put my conclusions simply, I don't believe the pills work without some other forms of talk therapy and behavioral/thought modification practices.  I got off the chemicals 12 years ago, while my siblings have continued.  Between the two of them, they probably take $30,000 worth of pills a year, so it isn't really a cost effective alternative to talk therapy.   IMO neither of them is anywhere near "cured" , but they (sometimes) seem superficially calm because they are drugged.  There have been all sorts of side effects, which then require other expensive medical treatments.  

I have known many other people who have taken anti-depressants outside my FOO and I don't know of an instance where it appears someone was cured long term by chemical treatment.  It seems there is usually a short term burst of energy and enthusiasm  as the drugs kick in soon followed by a crash.  The typical response is then to "adjust" the level and type of drugs.   By constantly changing the medication, the short term euphoria phase may be prolonged for years, giving the appearance of a "cure".   But from what I've observed, the patient isn't really getting better.  Two people I've known have attempted suicide after years of this cycle.     

When Prozac was first invented, maybe it was a cost effective alternative to therapy in some cases, such as short term situational depression.  But since then the price has risen 500% so I don't believe the cost or efficiency argument is really valid.  The whole thing has become a societal level "drug habit".  It's an easy answer when real cure requires time and hard work.  

[BonesMS]

Having experienced drug tolerance, I am very concerned that the insurance companies are insisting on ONLY drug therapy and nothing else!  I had to get off the merry-go-round of anti-depressants because they simply STOPPED working and the amounts needed were rapidly approaching toxic overdose levels!  Trying to convince doctors and insurance companies that I know my body better than they do (because I have lived in it longer than they have) seems to go over their heads.

Not everyone can be helped with drugs, drugs, and more drugs.  There is no "Magic Pill" that will CURE everything permanently.

Bones

[seastorm]

I think it is tragic that drugs are seen as the answer for people who are traumatized and/or mentally ill. Of course there are chemical imbalances that can be treated with drugs but even so, the collateral damage done to family and friendship systems by someone who has gone off the rails even temporarily requires that support and guidance of a profound kind needs to be provided.

I can hardly believe in the values and stupidity of a pharmaceutical approach to mental illness. My sister who worked as a psychiatric nurse at a University Hospital worked as a group therapist in the 1980s and she saw profound growth and change in people who participated over a period of 16 weeks. Just giving drugs is like putting a bandaide on a gaping wound.
There  is a lot written about how pharmaceutical companies bought off psychiatrists and how they vacated their responsibility to cliets by pandering to the drug companies.

Not everything is about money, but money drives so much of our culture. The mentally ill and the psychologically wounded are paying the price for the greed of both some professionals and the pharmeceutical companies.

Sea storm

[Dr. Richard Grossman]

Hi everybody,

Here are some of my thoughts on the article (let me apologize in advance for my tone!):


“Then (1972), 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.”

In truth, I’m not sure there’s that much difference between the two.  50-60 patients?  And he had an attachment to each one?  In my view, it is the relationship that is ultimately healing (brain re-wiring).  If he is seeing that many people, I doubt the relationships had much value.  I see about 10 people on a regular basis.  

“Then, he knew his patients’ inner lives better than he knew his wife’s…”

I feel sorry for his wife.

 “I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.”

The mystery and intrigue?  Of all of the aspects of being a therapist those would certainly be the at the bottom of my list.  If I couldn’t do this work, I would miss the knowing/sharing of a life—the joy of being connected to another person in a way the person has never experienced before.

“Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less..”

So that’s the reason I can afford to charge less (30 years later).  I always wondered about that…

“And to have your income reduced that dramatically was a shock to all of us. It took me at least five years to emotionally accept that I was never going back to doing what I did before and what I loved.”

He certainly could go back to what he feels passionately about if was willing to change his (and his wife’s) lifestyle.  Ultimately, one has a choice to make…

“Dr. Levin’s initial efforts to get insurers to reimburse him and persuade his clients to make their co-payments were less than successful.”

I have to wonder whether his patients’ refusal to pay their co-payments has something to do with his interest in the mystery and intrigue of psychotherapy rather than the relationship.

“Ms. Levin created accounting systems, bought two powerful computers, licensed a computer scheduling program from a nearby hospital and hired independent contractors to haggle with insurers and call patients to remind them of appointments. She imposed a variety of fees on patients: $50 for a missed appointment, $25 for a faxed prescription refill and $10 extra for a missed co-payment…
“This is about volume,” she said, “and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do it.””

Well, I guess if you are doing this for the money, you might as well go all out…

“She said she likes Dr. Levin and feels that he listens to her.
Dr. Levin expressed some astonishment that his patients admire him as much as they do.
“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.””

His patients believe he cares even though he barely knows them.  Very sad commentary…

“The Levins’s youngest son, Matthew, is now training to be a psychiatrist…”

Might I suggest becoming an investment banker?

Sorry, but I found the article to be grotesque (not that medication is unimportant—it is often life-saving).  It reminded me of my years working in psychiatry at Mass. General Hospital where the important things were status, politics, and money.
 
Richard

[Guest]

Richard, your crit cheered up my day, it's good to see someone else saying the things that I usually say, or sometimes just think. Thanks for that.

[teartracks]

Woah up Dr. G.,

I'm putting Aloe on - suffered first degree burns reading your critique of the NYT article  !

tt

[BonesMS]

I agree, Dr. G!

Personally, I would NOT go near a psychiatrist like THAT where all he wants to do is push pills and not get to know me as a human being!

Bones

[teartracks]

Dr. G.,

I was kidding in my last post.  I hope you could tell that!

But seriously concerning the article, I didn't read it.  Why?  Because people like me and most people I know  see ourselves outside (perhaps wrongly perceived) the elite target market of the NYT. 

I may be wrong, but reading your commentary made me think that Dr. Levin and the person interviewing him collaborated in their Q & A so that the interview had the highest possible appeal to it's general readership.   It's good to know that at least one pair of eyes saw past Dr. Levin's shallow double talk, yours!  It is scary to think that other Psychiatrists/practitioners will gobble up what he said and pirate/parrot his approach as a model for their own practice. 

Thanks for passing the article and most especially your thoughts on it to us here.

tt



   

[Dr. Richard Grossman]

Hi tt,

I knew you were kidding!

I thought your comment about the New York Times was interesting.  One of the things I have been interested in for a long time is human being’s desire/need for status—part of our evolutionary legacy.  Status in our evolutionary history led to more children plus increased resources and safety to keep these children alive.  Therefore, it is almost universally desired.  The desire causes great joy (temporarily) to some as well as great pain—when it is lost.  The loss of status often leads to depression.  Furthermore, the amount of money spent on maintaining status is staggering.  I joked about it in an earlier post on why “The North Face” is printed on “every” coat in the northeast.  One of the things I also wonder about is whether the human brain can be re-wired to reduce the need for status (or as Steve Pinker said in his wonderful book, How the Mind Works, “tell your genes to jump in the lake”).  I think this is very hard to do.  Of course the other option is self-deception—where we tell ourselves that we have higher status than we already do.  I heard second hand that David Brooks, in his new book, The Social Animal, reports that 90% of doctors believe they are in the top 10% of their profession.  This is part of our evolutionary/genetic makeup as well.  And status (and money) are two of the major reasons, I believe, that doctors become doctors in the first place.  The recent changes in healthcare reimbursement appear to be having a significant effect on doctor’s mental health:  the Jan. 2010 “General Surgery News” reported that 30% of surgeons screened positive for depression. 

Anyway, whatever the NY Times readership thinks of itself re: status, for the most part, the newspaper’s reporting is quite good.  I simply stick a straw into my mouth and deflate my head after each read.


Richard

[river]

  One of the things I have been interested in for a long time is human being’s desire/need for status—part of our evolutionary legacy.  Status in our evolutionary history led to more children plus increased resources and safety to keep these children alive.  Therefore, it is almost universally desired.   

......... I dont know if you've read any Viktor Frankl, he argues that such things as status, are not man's natural primary desire, but fulfiment of meaning is.  However, it is when the access to fulfilling meaning is blocked that the desire for power/ status/ pleasure takes over as a prime mover.   
I think that in this consumer society where people become commodities, true meanings and values are blocked, or put another way people get re-routed away from them in the stampede to look good, to have status, to remain comfortable, not have to question themselves etc.

These truths are what fit my experience, I have paraphrased Frankl, hope Im more or less accurate. 

[Dr. Richard Grossman]

Hi river,

Frankl was an extraordinary human being—and I think that, in part, is the problem with his beliefs about human nature.  He was able to do something—find meaning—in (and after) circumstances that almost no one else could.  I, and you, and perhaps many others who come to this board find the pursuit of meaning one of the most important goals of life.  But in my view, we, as a group, are very unusual.  I have not found this pursuit underlying the motives of the population at large—nor would this pursuit seem to make evolutionary sense.  (The pursuit/discovery of meaning would not lead to more children, or more resources to take care of them.  I’ve certainly discovered this (!)  Frankl, himself, if this is any measure, had only one child [I believe].)

This is in part, why I don’t consider myself a “humanist”.  The species has too many disturbing genetic qualities!  Rather, in my life I have tried to gather a small group of very special people together, my family, my patients, my friends, you and the rest of this group, (and of course my Golden Retrievers—Watson, and then Beau—who, everyone else complains receive too much attention) in the attempt to pursue meaning (love—in Frankl’s terms), do a little good, and not feel alone.

Richard