When therapy is all about the money

Is talk therapy going silent?

Not entirely, but the Saturday edition of the New York Times featured an article entitled “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy.” This is very old news to anyone in the mental health field — as a patient or practitioner. But it’s good to see that The Times has noticed.

Here’s the heart of the story:

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

 

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

 

Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.

The truth is that psychotherapy of any type has become unaffordable to the average American without insurance. Of course, this is true of all health care now, but the insurance companies, through “managed care,” have become particularly stingy about psychological services, whether delivered by an MD, an MSW or a PhD.

The Times article focuses on Dr. Donald Levin, a 68-year-old psychiatrist. He was trained in psychotherapy but says that he and his colleagues had to give it up when the insurance companies slashed reimbursement for it. He and the others limited their practices to diagnosis and drug prescription:

“At first, all of us held steadfast, saying we spent years learning the craft of psychotherapy and weren’t relinquishing it because of parsimonious policies by managed care,” Dr. Levin said. “But one by one, we accepted that that craft was no longer economically viable. Most of us had kids in college. 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 could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”

 

“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”

 

Dr. Levin would not reveal his income….

Kudos to Dr. Levin for his honesty.  I think his frustration about feeling “unable” to practice therapy is real. But — hello — he suffered emotionally for five years while he raked in so much money he won’t disclose the amount, all the while wistfully looking back?

The bottom line here, once again, is money and the expectation that a doctor should have a lavish income. (And I’m not ignoring the reality that psychiatrists often make less money than other specialists.)

In a reasonable system, doctors would be paid well but people would not be excluded from help because of capitalist motives. (That’s one reason Freud favored training of  “lay analysts.”)

Those greedy motives are ubiquitous. There has, for example, been a quite reasonable move afoot for some time to authorize clinical psychologists to prescribe psychotropic drugs as well as provide therapy. Of course, the psychiatrists go crazy at the suggestion — just as the psychologists go crazy when social workers attempt to invade their turf. It’s all about the money.

And, worst of all, the greed of the insurance companies and psychiatrists themselves perpetuates a pharmaceutical-based system that may actually do more harm than good. Don’t take my word for it. Read Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. He documents that cultures less reliant on psychiatric drugs have significantly higher recovery rates.

Meanwhile, unless you are a member of the “worried wealthy,” be glad you don’t require psychotherapy and drugs. Feeling slightly suicidal? Go ahead and splurge — have a face lift and a brain transplant or some other comparatively inexpensive feel-good treatment.