I have been in private practice for 30 years. Unlike most psychiatrists, I "insist" on providing both the psychotherapy and the medication management for my patients. I would not consider participating in any insurance plans especially managed care plans.
Unfortunately, managed care has pressured psychiatrists, particularly those completing their residency training over the last 15 years, to participate in "split therapy" and agree to provide medication management while non-medical psychotherapists do the psychotherapy. The younger psychiatrists tend to more willing to join a managed care program because they don't appreciate what the practice of psychiatry was really like prior to managed care. Naturally, they want to build a practice unless they have full time salaried positions.
There has been an emphasis on neuroscience, pharmacology and evidence based research in psychiatry. When I go to professional meetings, psychotherapy is mentioned almost as afterthought at the end of a lecture. The attitude seems to be that it "can't hurt," much like physical therapy is mentioned as an adjunct to orthopedic treatment. Notwithstanding the importance of biological treatment in psychiatry, there is no question that psychiatrists, like other physicians, tend to favor those treatments for which they are well paid. The reimbursement for 15 minute medication checks is good compared to a 45 minute psychotherapy session.
However, psychiatrists seem to have forgotten that it was not that long ago that the best minds in psychiatry had a psychotherapeutic orientation and graduation from a psychoanalytic institute was almost a prerequisite for advancement in academia. Despite popular belief, psychiatrists have excellent training in the techniques of psychotherapy.
I am unaware of any mental health expert ever saying that "split therapy" benefits anyone except for managed care executives. The insurer has a substantial increase in administrative costs in order to manage the professionals.
There are several problems with "split therapy." It assumes that there is frequent communication between the psychiatrist and the psychotherapist. In my opinion, this is largely fiction. Patients do not realize that their psychotherapist and psychiatrist often do not even know one another. This means that the psychiatrist knows little or nothing about the psychotherapist's approach to therapy. Since there are hundreds of schools of psychotherapy, this can be a major problem. Mental health professionals do not necessarily have the same level of talent and their professional paths would never cross were they not thrown together. They may not like one another! The psychotherapist may be put in the position of calling for an emergency psychiatric consultation if they suspect a drug side effect or are concerned about a patient's suicidal or homicidal potential. This is not a problem. What is clearly a problem are those cases where the psychotherapist overlooks something because of a lack of medical training resulting in a potential disaster.
There is one final problem that I face at least once a week. I will receive a phone call from a prospective patient who tells me that they got my name from a staff person at the insurance company or from the list of participating providers for their plan. When I tell them that I do not participate with any insurance plans, they often become irate. One poor woman told me that I was the ninth psychiatrist who she called. A man told me that the doctors he spoke to could not see him for six weeks. A woman was upset because the only available psychiatrist was a 45 mile drive one way. Another man asked me to recommend a few psychiatrists. None of the four doctors that I recommended participated in the plan.
Although psychiatrists, who handle both the medication and therapy, may come from different theoretical orientations, I believe that their approach to patients is similar. Patients want and deserve to be listened to in an unhurried fashion. They want to be taken seriously and their concerns need to be validated. Good psychiatrists listen and they listen "hard." Despite the jokes about the bearded analyst from Vienna, experienced professionals respond thoughtfully, spontaneously and respectfully. It sounds simple, but just try listening to someone with undivided attention for an hour, it is exhausting work. Psychiatrists who provide this level of treatment do not have to participate in insurance plans.
copyright 2010, Richard Sostowski, M.D., D.F.A.P.A.You can contact me either by calling my office at 908.766.5466 or via email at rich@forensicpsychnj.com