aboutnestachewebMs. Melinda Beck’s article  in the Wall Street Journal, “Mental-Health Care at the Doctor’s Office” (9/25/2013)– describes the integration of mental health care into medical agencies and  predicts how many patients will actually be served.  Let’s just say I think those of you who are going to receive those services need a little more information.  The author also does not not seem to be aware how psychiatric treatment is actually practiced out here in real America.

Don’t get me wrong.  I quite realize that integrated approaches, where mental health professionals are woven into the fabric of a medical clinic, are the wave of the future, where cost efficiency is dominant.  They are here to stay.  In many ways, I think they are a good idea. What I emphatically disagree with is that only handing someone a questionnaire somehow parallels or is equivalent to “good therapy”.  If those folks are “getting better”, it is probably that they are getting attention from the providers, they temporarily feel understood.  But if no new behaviors are being achieved, no new patterns of thought practiced, no new skills learned, no deeper emotions uncovered, then I doubt the long-term efficacy of the treatment.

Many consumers don’t know the basics of mental health treatment.  For example, the difference between psychiatrists and psychologists, social workers and licensed counselors. Psychiatrists are medical doctors: they have been to medical school.  They can be in administrative positions, research, can certainly do therapy, and like all doctors, can prescribe medications.  Psychologists have been to graduate school.  In a few states and situations, they can prescribe, but rarely still.  Psychologists are licensed to do assessment, research, and therapy.

Many psychiatrists in outpatient private practice talk to their patients for a few minutes about how they are doing on their medicine, a “med-check”, and that’s about it.  More complicated cases take more time.  They depend on psychologists, social workers and LPC’s (Licensed Professional Counselors)  to do the actual therapy with patients.  My patients tell me it is highly unusual for a psychiatrist to spend more than ten minutes with them, except in an initial evaluation.  There are exceptions to that I am sure.  This is not a criticism necessarily.  But in many areas of the country, psychiatrists are swamped.  So I don’t understand Ms. Brown’s point that this integrated approach holds some radical change for psychiatry.  That’s just not accurate from what my psychiatry friends tell me, and even the psychiatrists I have had as patients.

What’s the answer?  I myself practice a very direct, “let’s get to the point” kind of therapy that hopefully reduces the number of sessions that people have to have.  My patients work hard.  I work hard.  This addresses insurance concerns, but simultaneously honors that meta-analyses repeatedly show that it is the relationship between the therapist and the patient (Norcross & Lambert, 2011) that is a primary curative factor in psychological treatment.  That is to say:  the belief/trust that the patient has in the therapist and the efficacy/consistency that the therapist demonstrates in his/her treatment are what heals.

So what should you as a patient do?

  1. Your symptoms should be explained to you.  A diagnosis and treatment plan of some kind should be outlined by your therapist, whether in one  of these clinics or in private practice.  That can look different with different modalities of therapy, but there should be some discussion of how you are supposed to improve.
  2. You should expect to get/feel better.  Your initial symptoms should be improving.  You have to do your part.  If you are, you should be getting better.
  3.  If medication is recommended, you should ask why that particular medication is being used, and for how long the medical professional believes it should be prescribed.  What do you need to do in the meantime to improve your mental status?  Pills don’t fix everything.  They just don’t.
  4. You should feel trust and and connection with your therapist.  Whether you see them twice or ten times, you should feel that they are closely attentive to you.   I don’t know how many times I have heard, “She/he talked a lot about her/himself” or something like that.

I would hope that in these integrated practices,  “using a standardized  nine question depression quiz” is simply a starting place, and a more full-service approach to serving the patient is called for.  If you are not receiving that, I would recommend that patients ask to be referred to other mental health professionals where more effective work can occur.

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