Shirah Vollmer MD

The Musings of Dr. Vollmer

Is Psychotherapy Research The Answer?

Posted by Dr. Vollmer on July 22, 2015

http://www.nytimes.com/2015/07/19/opinion/psychiatrys-identity-crisis.html?_r=0

“The brain is notoriously hard to study and won’t give up its secrets easily.”

Eleanor, a blog reader, pointed me to this article, reminding me that I am not alone in my fight against the reductionistic approach to mental illness, either by promising a magic bullet, in the form of a pill, or a procedure, such as Transcranial Magnetic Stimulation, or by the form of a short-term, cookbook type of psychotherapy. In this New York Times, opinion piece, Dr. Richard A. Friedman argues that more federal dollars should be directed towards psychotherapy research. He reminds us that Dr. Markowitz published a study on PTSD where the helpful treatment was Interpersonal Psychotherapy, as opposed to exposure therapy. In other words, people with trauma need to re-build their relationships, and not just desensitize themselves to their triggers. My issue here is that psychotherapy research, although potentially promising, does not account for the individual differences between psychotherapists, along with the individual differences in the length of treatment required. We share this issue with physical therapists, who also do not have good evidence for how many sessions are needed for a back or knee injury. The numbers become arbitrary and so the payments are helpful to some, but not to all with physical complaints. Likewise, if insurance pays for 12 psychotherapy sessions, then this will help some people, but for many people this will not suffice. Is some psychotherapy better than none? I think so, but for training purposes, the therapists need to learn long-term psychotherapy in order to use those skills in a shorter-term setting. Dr. Friedman only highlights our identity crisis further, which by that I mean, that promoting psychotherapy research could also send us down the rabbit’s hole. How do we justify our work, if we assume that people have deeply unconscious reasons for symptom formation, and as such, the length of treatment is not knowable, and the measure of success is also not knowable. Patients often sit with ideas that we have generated in my office for months and years before the concepts penetrate, allowing them to release themselves from their self-imposed shackles. Healing is slow and not steady. Dr. Friedman and I agree on this, I am sure. Where we part ways is how the government, or insurance companies should support our treatment. Funding neuroscience is only partly the answer. On this, we concur. Funding psychotherapy research is questionable in my mind, and hence our ideas diverge. My suggestion: Introduce patients in psychological pain to psychotherapy, paid for by insurance, with a limit of 20 sessions per year, so that the patient and the therapist can try to find a way to fund the other 30 sessions, knowing up front, that those 20 sessions may help with symptom relief, or it may not, and as such, the journey begins, but the endpoint is not known and it is not knowable.

5 Responses to “Is Psychotherapy Research The Answer?”

  1. Nope. If somebody told me I had 20 sessions of psychotherapy a year to treat my complex PTSD (gained from 25 years of truly severe abuse), I would be suicidal. I’ve been going to therapy twice a week for 15 months. I’m just getting to the point where I may be able to consider one session a week. If I had rheumatoid arthritis or diabetes, nobody would question all of the appointments I might need to keep myself stable. I am very lucky that my health insurance provides parity with physical health and mental health. My psychotherapy sessions have the same copay as going to see my primary care physician. 20 sessions a year probably could not provide symptom relief for me, because all of the buts and pieces of my trauma plus other symptoms need to be addressed, not just have a Band-Aid applied. I am pretty sure that Band-Aid would fall off before the ne,t several months were over. And there would be no way for me to fund the entirety of my mental health treatment.

    • Hello Pattsypathtohealing,
      I completely agree with you. I am happy that you have good insurance which supports the help you need. Most people are not so fortunate, so there has to be a solution for people which makes financial sense. Again, my heart is with you. Complex trauma involves a deep understanding and working through, which takes time and patience. Thanks for chiming in.

  2. Eleanor said

    I have been told by a friend in the insurance business that, to pay for psychotherapy, (say after the initial 20 or so sessions or whatever they officially cover), they need to see “proof on paper”…… lab reports, scans, pathology results, brain imaging, electronic records, etc etc. as proof the treatment method is working. I agree with you Shirah, that psychotherapy “research” is problematic and inconclusive for reasons you mentioned but the thought occurred to me that maybe this is what insurance companies need as part of their “proof on paper”. The ignorance involved in this kind of reasoning leaves me virtually speechless. Emotions, fears, feelings, mental pain, overwhelming struggle, etc. can’t be put on a graph. And what about those who need much more that once a week psychotherapy? What about those patients? Guess they are just outta’ luck. So sad.

    • Yes, very very sad. When Prozac came out in 1988, insurance companies thought this would bypass psychotherapy and they were telling patients that if they refused medication then they would not pay for any treatment. The hope, on their end, was for medications to replace psychotherapy and thereby save dollars. Unfortunately, psychiatrists bought into this notion and hence the ground was laid towards an evidenced based approach, which, as you clearly state, makes sense for treating hypertension or high cholesterol, but when it comes to mental life, there are no objective measures, and hence we are in a world which defies common sense. Now, all these years later, we can see how we lost our way. We let loose the banner of treatment as a journey, as opposed to a band-aid. With this loss, we, as “psychopharmacologists” can be replaced by “collaborative care” models, where the mainstay of treatment is done by primary care. Then, fewer psychiatrists are needed to prescribe medication, and then, without psychotherapy skills, what does the psychiatrist do now? This is a story of short-term gain for long-term pain. Many of us saw it coming, but that is cold comfort, to a profession which used to get excited about the relationship with patients. Thanks.

  3. Shelly said

    But won’t limiting psychotherapy to 20 sessions per year give patients a false sense of security–that their pain and suffering will be officially resolved by the end of the treatment period? Even if you discuss in your sessions further therapy, most patients would feel that 20 has been chosen because within that time, they are expected to “feel better.”

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