Hooked: Why psychiatry must reinvest in the power of psychotherapy

Dr. Joseph Sokal is the Regional Chair of Psychiatry for the Texas A&M Health Science Center College of Medicine’s Bryan-College Station campus, and a member of the Texas A&M Physicians practice. He will speak tonight on the TAMHSC Bryan campus about psychotherapy and its diminished role in psychiatric treatment as part of the College of Medicine’s Mini Medical School. The public talk will be streamed live on the college’s UStream channel. We sat down with Dr. Sokal to discuss the driving forces behind current trends in psychiatry and his vision of sound psychiatric care.

TAMHSC-COM: How is psychotherapy perceived in an age that has shifted to chemical or biological explanations for mental illness dominating public discourse and scientific research?

Dr. Sokal: As pharmacological therapeutics became available, there was great excitement that pharmacology alone could address the various diagnoses that we treat. So there was a movement away from psychotherapy in academic psychiatry, beginning in the 1970s and reaching a crescendo in the ’90s or late ’80s.

That doesn’t mean that before that time, no one thought there was a biological basis for mental disturbance. Freud himself, the pioneer of psychodynamic psychotherapy, thought that ultimately a lot of what he was treating would eventually be managed biologically.

More recently, there has been a renewed interest in psychotherapy because in the last 20 to 30 years a fairly solid database has emerged which demonstrates convincingly the effect of one particular type of psychotherapy, cognitive behavior therapy, in treating depression, anxiety, and several other conditions or patterns or syndromes. It’s even being used now with some good benefits in helping people with schizophrenia help deal with their auditory hallucinations.

So there has been a swing back in interest in psychotherapy. But the funding streams for psychiatric practice have biased psychiatrists toward medication management. While therapy is often done, it is rarely done by psychiatrists, but is done in outpatient settings, by psychologists or social workers.

COM: Isn’t one of the key distinctions of a psychiatrist that they can prescribe medications?

Sokal: Yes, but as a priority or a focus of their activity, I would say that’s kind of a byproduct of what people get paid for. A psychiatrist will probably get more from medication visits than therapy. So a practice will often drive psychiatrists away from practicing psychotherapy, and patients will go to psychologists or social workers at a lower rate.

Now, within psychiatry, there are still many people who believe it is critical for psychiatrists to know how to practice psychotherapy. So the American College of Graduate Medical Education has mandated that psychiatrists learn how to do psychotherapy. Sadly, the mandate is not matched by clinical opportunity. So the training in therapy has been less intensive for psychiatrists than it was in the past.

COM: Is this specialization driven by how complex drug interactions and pharmaceutical options have become? You don’t go to a neurosurgeon to treat a cold; should you go to someone with a psychiatrist’s level of expertise if you don’t need the thing that is their highest level of training?

Sokal: I would say in part. But I would argue that as a culture we have rushed faster to metaphors for what we hope to know in the future than actualities on the ground. Meaning, we know much less biologically about depression say than a simple statement that there is a chemical imbalance and we give you a drug and it fixes it. That is a fiction. Yet it is the case that we have therapeutics and we know the mechanism of action and based on this we presume we know the cause of depression.

Let me try to put that in a more balanced way. It is extremely reasonable to believe – even to say we know – that all psychological phenomena have a biological correlate. But to move from that knowledge to a simple cause-effect is premature. And also, at this point in time we do not have a clearly articulated biological pathway that is always present in all people who are depressed. Or at least we haven’t found it yet. We see certain pathways that seem to be prejudicially indicated. Remember depression is a syndrome. It isn’t a disease, it is a cluster of symptoms – five out of nine symptoms. Why is it five out of nine instead of six out of nine?

COM: I don’t know.

Sokal: Because it was decided by a committee of people who thought that five out of nine sounds good. In other words, psychiatrists hope that by coming up with a set of diagnostic criteria we can group like with like. But things that appear the same can be a lot different biologically. So it’s a very early and provisional approach.

COM: Anyone who has had experience with someone, or with multiple people, who have been on antidepressants knows that these drugs can interact with different individuals in very different ways.

Sokal: Also, at least one good study has suggested that antidepressants really only become clinically meaningful in cases of severe depression. It isn’t saying they aren’t useful, just that it they are not worth the cost except when depression is severe. And by cost I do not mean money. Medications are not benign. They have side effects, and they can cause some real problems. As a psychiatrist, in most instances of depression, not all, I will recommend therapy first.

COM: One stigma of psychotherapy, or at least some forms of it, has been that it is very open-ended and can go on a very long time. This seems especially problematic at a time when the national conversation is focused on both containing health care costs and expanding mental health coverage.

Sokal: There are all sorts of forms of psychotherapy. When we talk about psychotherapy we are really talking about a diverse range of practice, which can run anywhere from ten sessions to years, depending on the type of therapy.

But the question you’re asking is a technical one. If I am designing a medical system, do I want my psychiatrist doing therapy? Is that an efficient use of their skill set? It’s a difficult question to answer. There is some evidence that providing both may be more efficient than splitting treatment. Certainly when you’re working with someone in therapy you have a much deeper sense of the origin and the role of symptoms, and a better view because you’re talking with them more, in terms of their mood state. Or at least that’s possible – let’s say that. If you split the treatments, someone is going to a psychiatrist and also a psychologist. The psychologist will charge less, so in that sense you are saving money, but you’re paying two doctors’ fees.

The other thing is that people will often go to a psychiatrist first, or a family doctor first, they may be prescribed medications without considering therapy. And if our first obligation is to do no harm, we may be doing harm.

I can’t show you cost studies, but I can say there are costs paid at least by a psychiatrist not doing a sophisticated evaluation. And to do that, you have to have a pretty good understanding of some models of human psychology and a deeper understanding of the causes and nature of human suffering than a simple “symptoms equals medications” perspective.

The question is really at the heart of psychiatry’s identity. Historically, many people are drawn to psychiatry because they want to understand and connect with people at a very deep level. When you approach people from a symptom based perspective, it often leads to a less deep and meaningful connection. Not always, but it can. So in particular in psychiatry where the relationship is focused on and valued, they’re not in contradiction but they can work in different directions. A purely medication-based perspective can set up boundaries that will not be helpful in terms of a patient’s overall health.

In the rest of medicine, the thing you look at is not just the price of specialization, but what is lost when you spend less time with individuals. You can tell me you saved money by spending five minutes less with patients. And that may show results for five years. But what are the long-term consequences of spending less time with patients? Whenever you talk about efficiencies, it’s really important to talk about your timeline, and costs you may not notice upfront.

COM: Can you elaborate on this?

Well, let’s look outside of medicine. The classic example of this effect now is outsourcing. It looked like a great idea. But some sectors of manufacturing are recognizing that you lose a feedback loop between designers and producers that can lead to advances in the construction of products. It’s easy to talk about efficiency and what that typically motivates is looking at “how can I cut costs now?” But I’m not sure in the long run that you’re accomplishing what you want to accomplish. And I think that’s really pertinent when it comes to time spent with patients.

COM: What do you think psychiatrists should be focused on in their practice?

Sokal: There is a morphing understanding of what an illness is, and what should be treated with medicines. There is a lot of subjectivity. I’m not saying it’s wrong. But many people would say that medication for hyperactivity is more like cosmetic surgery than like heart surgery. “I’m better with it than I am without it.” Does that mean I needed it? Does that mean that I was sick before?

These are deep questions, and I’m not saying I know the answers. But for economic reasons psychiatrists are seeing people for less time, and using often use a purely symptom-based approach that leads to conclusions that result in prescription of medications.

What we would hope from psychiatrists is that they would offer a more penetrating and comprehensive understanding of a person’s symptoms than a simple diagnosis of symptoms and prescribing medications. That is poor practice of psychiatry.