Just take a long, hard look at what has become of the profession
of
psychiatry. Today, approximately ninety-percent of
psychiatrists no longer provide psychotherapy - once the mainstay
of traditional psychiatric treatment - to their patients.
Why is
that? For a few reasons.
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First, psychiatrists and their patients
were disillusioned and frustrated with
psychotherapy, its expense, duration, and limitations,
especially in the treatment of more severe mental disorders such
as
bipolar illness,
schizophrenia and
major depression.
Hopeful advances in the development of
more efficacious pharmacological therapies fueled the biological
revolution in psychiatry.
The seminal contributions of
Freud, Adler,
Rank and Jung to depth psychology have sadly
lost favor among most psychiatrists today. And the dubious
benefits of Ellis and Beck's
cognitive-behavioral therapy, while more medically
accepted, are rather condescendingly perceived by most as, at
worst, innocuous, and at best, merely a minor adjunct to
pharmacological treatment.
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Second, it's a turf war:
Prescribing psychotropic drugs places psychiatry in a unique,
lucrative and powerful position.
Right now, with the exceptions
of Oregon, Guam, Louisiana, New Mexico, and pending legislation
to grant clinical psychologists obtaining one to three years
additional pharmacological training prescription privileges in
several other states, psychiatrists are the only mental health
professionals licensed to prescribe such medications in the U.S.
The American Psychological Association has taken a stand
supporting prescriptive authority for properly educated clinical
psychologists. Organized psychiatry vehemently protests such a
trend.
How, readers might wonder, with this professional and
political tension between the American Psychiatric Association
and American Psychological Association, do psychologists and
psychiatrists currently work together in treatment?
Most (but
not all) clinical psychologists today are fairly well-versed
about psychiatric medications, via both experience treating such
patients and having taken at least one course in graduate school
and/or post-doctorally in this area.
In my own practice of
clinical and forensic psychology, when I believe that one of my
patients could likely benefit from psychiatric medication of
some sort, I refer them for a medication consultation to one of
several psychiatric colleagues with whom I have established a
professional relationship over the years.
While I may have some
suggestions regarding the type of medication to be taken, the
psychiatrist (many of whom today see themselves exclusively as "psychopharmacologists")
makes the final decision on whether or not to medicate and what
type of drug to prescribe at what dosage, based on his or her
own independent evaluation of the patient.
Psychotropic
medication can be tricky, and, while any physician is legally
permitted to prescribe them (and many do), psychiatrists have,
by far, the most hands-on clinical experience and expertise in
dealing with these potentially dangerous and sometimes
life-saving drugs.
But, unfortunately, both medical psychiatry
and the general public tend to overestimate the power and
importance of biochemistry, neurology and psychotropic drugs in
mental health while minimizing the basic role of psychology in
both causing and healing mental disorders.
Once patients have consulted with the psychopharmacologist,
something that can occur at the start of treatment or at any
point later on as needed, they typically continue to see me for
psychotherapy.
As part of their therapy, we discuss how the
psychiatric consultation went, whether they intend to take the
recommended medication as prescribed, and review what might be
expected regarding their symptoms as a result of doing so or not
doing so.
Many patients are quite
fearful of, reticent or resistant to taking any medications
in general, let alone psychiatric medications, and require a
sometimes prolonged opportunity in therapy to voice their
concerns, doubts and anxieties before being willing to even
consider a psychiatric consultation or trying medication.
If
they do decide to follow the prescribed drug regimen, patients
require regular and consistent support in staying the course
long enough to start feeling some benefit. This is especially
true of the
antidepressant medications, whose sometimes unpleasant
side-effects (e.g., dry mouth, constipation and diarrhea)
typically precede any therapeutic effects by several weeks.
Part
of psychotherapy in such cases involves encouraging the patient
to continue taking the medication despite those side-effects
long enough for it to fully kick in.
Of course, it is primarily
the prescribing physician's responsibility to address severe
side-effects, to adjust dosing when needed, and to try different
or additional drugs if the first aren't adequately alleviating
the patient's symptoms.
Consultation between the prescribing psychopharmacologist and psychologist can be essential in
sharing information regarding the patient's progress or
problems, especially since the treating psychologist typically
has more regular contact with the patient, and can more closely
monitor his or her mental status.
Currently, the California Board of Psychology's official
public position is that clinical psychologists (a highly
specialized type of training that not all generic psychologists
share) are legally and ethically within their scope of practice
when discussing psychiatric medications and their possible
utilization with their patients and other health professionals:
"Psychologists may discuss medications with a patient...,
suggest to a physician a particular medication to be prescribed..., may engage in a collegial discussion with a patient's
physician regarding the appropriateness of a medication for the
condition being treated..., [and] has primary responsibility
to monitor the patient‘s progress in psychotherapy, which
includes assisting in monitoring the changes which may be
attributable to the medication in the patient."
This has become
an important and routine part of the practice of clinical
psychology, since so many patients either have previously taken,
presently take, or could potentially benefit from psychiatric
medications as part of their therapeutic treatment plan.
However, having said all that, my own position on this matter
is that psychiatric medication is seldom, if ever, a substitute
for psychotherapy.
Psychotherapy is not (or shouldn't be)
secondary to phamacotherapy, but rather the primary mode of
treatment, with pharmacotherapy supporting psychotherapy, not
vice-versa. In most cases, patients who take these medications
should be in concurrent psychotherapy. (Yes, even patients
suffering from psychotic disorders.)
For one thing, they need to be
carefully monitored as to serious side-effects such as suicidality, homicidality, psychosis, mania, agitation or other
untoward tendencies, something that prescribing psychiatrists or
general practitioners typically do these days only on a very
limited, sporadic basis, and at significantly longer intervals
than once or twice-weekly therapy sessions.
Indeed, most
psychiatrists, psychopharmacologists and other physicians today
work in tandem with psychologists and other mental health
professionals, depending on the psychotherapist to see the
patient more frequently and to spend more time doing so.
So most patients seen by
psychologists and taking
medication today have two separate providers: the
psychiatrist/psychopharmacologist or non-psychiatric physician
and the clinical psychologist or psychotherapist.
At one time in the not too distant
past, all psychiatrists were well-trained not only to provide
psychopharmacological treatment, but to practice
psychotherapy too. In this case, the patient only needed to
see one clinician, who provided both psychotherapy and
psychopharmacology - a seemingly more efficient and
self-contained situation for both patient and doctor.
But, despite the fact that there are
still some psychiatrists (some of whom are
Freudian or Jungian analysts) providing both therapy and
psychopharmacology, those days are, for the most part, long
gone. And, unless
psychiatry does a dramatic about face - recognizing the true
limitations of psychopharmacology and placing more emphasis and
value once again on the practice of psychotherapy - they seem
unlikely to return.
Now the crucial question being
raised is whether clinical psychology will attempt to step into
that dual
psychotherapist/psychopharmacologist role once historically
occupied by psychiatry.
The potential problem with that
scenario is demonstrated clearly by what has happened in and to
the field of psychiatry over the past few decades. Psychotherapy
receives increasingly less emphasis in psychiatric training and
practice today as compared to decades ago.
One reason for this has to do with
the popularity of pharmacological treatments for
mental disorders not only with the general public, but
especially with insurance companies, who would much rather pay
for relatively rapidly-acting, inexpensive pharmacological
therapy than more expensive, prolonged psychotherapy.
While this policy is rationalized
and defended as being supported and indicated by evidence-based
scientific research, the truth is that no studies to date have
demonstrated psychopharmacology to be superior than
psychotherapy in treating mental disorders, especially over
time.
In fact, studies tend to suggest that psychotherapy is
superior in most cases to psychopharmacology alone, and that,
for many disorders, a combination of psychotherapy and
psychopharmacology is the most effective treatment.
Indeed, as more longitudinal
research emerges, the efficacy of psychopharmacological
treatment for psychiatric disorders, and its benefits versus
risks ratio is becoming increasingly questionable.
The reality is that psychotherapy
and pharmacotherapy do different things in exceedingly different
ways.
One cannot substitute for the other.
Both have their rightful place in treatment when necessary.
Unlike medications, real psychotherapy goes beyond mere symptom
suppression. Some mental health consumers seem to intuitively
understand this, choosing psychotherapy over pharmacotherapy,
psychology over psychiatry.
And we may even be seeing the
beginnings of a
consumer backlash against psychiatry and its lopsided
biological treatment of mental disorders. Nonetheless,
pharmaceutical companies and most biologically-oriented
psychiatrists continue to mislead the public into believing
these drugs are miraculous substances sufficiently efficacious
as to render psychotherapy a comparatively archaic and virtually
obsolete treatment approach.
This does a grave disservice to the
community. Nothing could be farther from the truth. Most people
suffering from emotional disturbance who receive at least
several sessions of psychotherapy - any type of therapy - are
far better off than untreated individuals.
And, in at least one study (1998),
50 percent of patients noticeably improved after eight therapy
sessions, while 75 percent of individuals in psychotherapy
progressed by the end of six months. Research suggests that
psychotherapy is frequently at least as effective as medication,
and that the benefits are more enduring.
While we are fortunate to have such
potent pharmacological agents in our therapeutic armamentarium
today, they are certainly no panacea, have profound limitations
in what they can and cannot do, and carry potentially dangerous
and disturbing short and long-term side-effects, including, in
some cases,
...to mention but a few.
So why are psychologists so anxious
to prescribe? Of course, the main argument is that we would be
in a better position to serve our patients needs for both
medication and psychotherapy.
That there is a severe shortage of
psychiatrists, especially in rural areas, and that prescribing
psychologists would make medication more accessible to those who
most need them. And perhaps more affordably. Maybe so.
Would it be more convenient for me
to prescribe psychiatric medications to my patients rather than
referring them to a colleague to do so? Absolutely.
Could I make more money by providing
brief medication consultations and follow-up visits to patients
instead of spending forty-five minutes with each patient doing
psychotherapy? Of course.
After all, there are only so many
hours in a day. And, therefore, only a very limited number of
psychotherapy patients one can see.
(From a financial standpoint,
because of the enormously increased risks of prescribing
psychotropic drugs to patients, malpractice insurance would
become considerably more expensive, possibly limiting these
eagerly anticipated economic gains.)
My main concern is that since
writing prescriptions for a psychotropic drug is far easier and
less time consuming than psychotherapy sessions, clinical
psychologists will very quickly succumb to the demand for these
drugs and to the powerful allure of making a much easier buck.
The tempting siren call of
psychopharmacological treatment, which has already lured
psychiatry to near wreckage on the rocks, now beckons
seductively to clinical psychology.
And it grows ever more appealing,
almost irresistible, as the combination of public craving for
quick and easy physiological fixes such as psychiatric drugs and
poor public relations portray psychotherapy to be a less
desirable and inferior type of treatment. Prescribing
psychologists could compete equally in the market place with
psychiatrists.
And would no longer be limited to
providing only psychological treatment.
But is this a good thing? I don't
think so.
Clinical psychology would quickly
deteriorate into something akin to what psychiatry has become.
Psychotherapy would be all but abandoned by most, as it has been
basically by psychiatry. And this would not be in the best
interest of patients' well-being. They would be left in the
lurch, forced to seek out lesser trained, less qualified, less
sophisticated master's level clinicians to provide
psychotherapy.
Not that such non-doctoral
clinicians cannot provide adequate psychotherapy. They can, and
many are capable of far more than merely adequate therapy.
But the consumer will have taken a
hit in terms of the type of psychotherapists they could see.
Indeed, this might exacerbate the already disastrous trend
toward minimally trained, unlicensed, pseudo-therapists,
psychics, life-coaches, exorcists, etc. filling this void. Now
is not the time to abandon the healing (though admittedly still
evolving) art of psychotherapy developed over the past hundred
years.
This would not be progress, but a
fatal mistake and failure of courage and commitment on the part
of clinical psychology to take up its banner and champion its
worthy cause. And psychotherapy, already embattled, wounded and
weakened, will have received yet another death blow, another
fateful nail in its coffin. (See my
prior post "Denial
and the De-Souling of Psychotherapy - A Reply to 'Is
Psychotherapy Dying'?".)
It is devilishly difficult to
faithfully serve two masters.
