Psychiatry Without Psychotherapy

From the good news / bad news department: Mainstream media sources are reporting that American psychiatrists have essentially stopped practicing psychotherapy. Rare exceptions occur with private paying clients. The majority of psychiatrists are dealing almost exclusively with medication management.

Over the last twenty years, the percentage of psychiatrists offering talk therapy has declined from a little less than half to a little more than one quarter, according to the most recent National Ambulatory Care Survey. As a result, the success rates for treating depression and anxiety have slipped. This likely because a combination of talk and medicine is customarily the preferred treatment for these common conditions.

The main cause is managed care. Insurance companies prefer the faster and cheaper route to symptom management: pills. This would seem to be bad news for clients, bad news for therapists, and bad news for anyone concerned about the mental health of the general public. So what good news could there possibly be?

Well, if you’re a provider of talk therapy who isn’t a psychiatrist, you may find reason to smile about this. It promises that an increase referrals to psychologists, social workers, and Marriage and Family Therapists (MFT) lie in the future. Although the study did not look at this trend in particular, anecdotal evidence, reports from talk therapists and managed care case managers suggest therapy is still happening. It is just that non-medical (and therefore, not by coincidence, lower paid) professionals are providing it.

An insurance company may not want to pay two to three hundred dollars per hour for the listening ear of a psychiatrist. For example, a lower reimbursement rate given to a social worker may be up to 50% less or lower and limited to perhaps 24 visits per year. Lower rates allow them keep their profit margin while still being able to say they support the proven results of psychotherapy.

So in practical terms, this may not be so bad. Psychiatrists can focus more on training as experts in psychopharmacology, a profoundly dense and complicated field that is only growing in complexity. Meanwhile, other professionals can develop relationships with local psychiatrists and managed care companies to increase our referral base and get paid to do what we love. And continue to be sought and compensated for what we were trained to do: psychotherapy, pill free.

© Copyright 2008 by Daniel Brezenoff, Licensed Clinical Social Worker, therapist in Long Beach, California. All Rights Reserved. Permission to publish granted to

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Courtney


    August 15th, 2008 at 4:27 AM

    I hate that there are so many psychiatrists out there who are bound by the insurance companies who basically tell them what they can and cannot do to help people. That is one huge thing that is wrong with the system of medicine in the United States as a whole. The insurance companies are in more control over what happens to patients than the doctors are! That is just wrong. Furthermore there are people for whom medication is not the right thing to do. Psychotherapy and talk therapy still have their places- it worked for many for years. Why is it that just because there is an expensive drug on the market that claims to help that other forms of therapy are being abandoned? This may be good for counselors and such but not for the millions of patients who are actively seeking help and all they get in return is a prescription which may or may not work for them.

  • Jim Hutt, Ph.D.

    Jim Hutt, Ph.D.

    August 15th, 2008 at 5:00 PM

    Your post is a great one, because it triggers all sorts of thoughts from this clinician of almost 30 years. I thank you.

    This is a very complicated issue. Yes, managed care plays a role, but is not the only influence–not by a long shot. There isn’t enough room here to elaborate on all the salient issues as I view them, so I will focus on the highlights, as I see them.

    Managed Care: It (managed care) is more a result than a cause. Remember (if you’re old enough), managed care originated from insurance companies. Insurance companies were, and have always been, a pathology-based, necessary element of the medical community as third-party payor conduits to MD’s. Psychologists, LCSW’s and MFT’s interjected themselves in to this system, naive to the implications. There was a time when they were reimbursed nothing. In retrospect, it should have stayed that way, in my opinion.

    Unless you are 50 years or older, you probably do not remember the years we were not reimbursed, and how unfair it all seemed. So, with huge political push, non-medically trained clinicians got on the gravy train. In my opinion, this was a bad move in the long run for clinicians. Why? Because probably 90%, or more, of our clients are not sick, in the medical model sense. But, by virtue of having to justify need for payment, we have had to pathologize our clientele who, by and large, do not fit the medical model. That continues to this day. Realistically, I could make a good argument that the pathologizing of those who aren’t sick is the fault of the psychology/MFT/LCSW community. It is also fundamentally unethical. But it certainly did not largely occur due to psychiatry.

    Nevertheless, literally all the clinical licensing support organizations, i.e., AAMFT, CAMFT, APA, lobbied state legislatures to include their constituents/licensees in the third party payor system. And it worked. Thereafter, turf battles ensued between psychologists and MFT/LCSW folks for a piece of the reimbursement pie, claiming psychologists were really the only non-medically practicioners trained to do the work that insurance companies should reimburse for.

    Insurance Companies and Talk Therapy: Talk therapy originally was acceptable as a reimbursable treatment entity when provided by a psychiatrist. Talk therapy occurred as both mainstay and adjunct to, and part of, the treatment plan provided by a psychiatrist. Frankly there wasn’t a whole lot of medical-based talk therapy going on prior to 1960 relative to all other medical procedures reimbursed. It comprised an miniscule rate of utilization of medical reimbursement.

    Meanwhile, there was plenty of talk therapy going on by the Jungians, and others, by a group of people who quietly served those with the resources to pay for it. They practiced a far less pathology-based model of therapy, to the extent that it existed. But the fact remains, the insurance companies, no matter what form they have taken, have never wanted to pay for talk therapy. They have done so grudgingly.

    By the way, several studies over the past 20 years or so, has shown that those individuals who have counseling of some sort have lower medical utilization rates. Clearly, talking helps. So, even if utilization rates for therapy go up, it is ultimately less expensive then major medical expenses.

    Once all the other disciplines, ie., APA, LCSW’S MFT’S, got in to the act, utilization rates went through the roof, which raised the eyebrows of the insurance companies, not to mention the major medical community. We began to take to big of a piece of what the medical community thought was their pie. The physicians did not like this. I’m not implying greed played a role, I’m saying it directly: greed has had a significant impact on the matter of medicine in general, and reimbursement in particular.

    Drug Companies and Reclaiming The Pie: One way for the medical community to get back the portion of the pie they lost to non-medical clinicians is to skin a cat of a different kind. Make a medical diagnosis, focus on the biological aspects of illness, make the non-medical clinician jump through justification hoops on the claim forms, throw money at research, (much of which, by the way, IS a good thing, but that’s another story for another time) develop alternative drug therapies, put treatment back in the hands of the MD’s, and reimburse only or mainly for that.

    Ultimately, that makes the term ‘managed care’ is a misnomer. Managed Payout is more accurate, in my opinion. Why? Because care is not what is being managed, that’s being mismanaged. Money is being managed, and if you look closely, the insurance companies are quite health financially.

    Psychiatric Inpatient Units: Many of what were previously open, unlocked psychiatric hospital inpatient units are now closed and locked units. Indeed, they house and care for some some very sick people, and have a very important function. Ironically, so did the previous open, unlocked units. But on those units, they had much longer stays, focused on talk therapies individually and in groups, and medication was an adjunctive therapy. There also were far fewer medications to choose from in those days. Now, it’s the reverse: The stays are short, and the list of meds is as long as your arm, and many of the units are locked. And for the most part, talk therapy is not an adjunctive therapy–it doesn’t exist. Stanford Hospital is a good example of this, and I’m sure others exist as well.

    Psychiatry: Now, because the tide has shifted to medication first, and talking last or not at all, psychiatrists are no longer trained, at least in most of the residencies, in talk therapy. And they don’t need to be, because talking is not reimbursed. Indeed, I get more referrals now than ever before because of that. What’s interesting, however, is the fact that the biggest group of prescription writers of antidepressants is not psychiatrists–It’s OBGYN’s! (Note: include that tidbit in your practice marketing plan).

    The long and short of it this: get as far away from third party payers as you can. De-pathologize your practice, if you haven’t already, and focus on the strengths of the people you see. It works.

  • daniel brezenoff

    daniel brezenoff

    August 15th, 2008 at 10:15 PM

    I appreciate both of your comments, and I essentially agree with you. In fact, in my practice I only accept private pay. But in my day job coordinating a partial hospitalization program, I am in close contact with the medical model. It leaves a bad taste in my mouth, but it’s the job I have, and I need to take care of myself and my family, so for now, like many professionals, I try to make the most of a rotten situation. My intention is to reach clients (we call them clients, but they are treated like patients by the institution) at the human level, the level of meaning, relationship, choice, reason, etc, as opposed to viewing them as sort of biological machines. And still, we are hostage to the insurance system, to allopathy, to pharmacology. I don’t like it any more than you do. That’s why in my private practice I don’t bother, and the work is the better for that. On the other hand, we all have colleagues who depend on the system to support their practices, and they serve clients who might otherwise get nothing but pills. In the long term, I’d love to see the whole system change, but in the short term, I’m not disappointed to see talk therapy part ways with psychiatry if that means the system supports more non-medical professionals and interventions. Whether that will in fact occur is an open question. My sincere thanks for reading and writing.

  • daniel brezenoff

    daniel brezenoff

    August 15th, 2008 at 10:17 PM

    PS: It IS a complicated subject, but I only get 300 words!


  • Ally


    August 18th, 2008 at 5:05 AM

    And what about those clients whose only means to get the care that they nedd is vis their insurance plan? What do you do about or how do you feel about having to turn them away since you only accept private pay?

  • Lisa Brookes Kift, MFT

    Lisa Brookes Kift, MFT

    August 18th, 2008 at 7:56 AM

    I think it is a shame for a lot of psychiatrists who would like to be doing “talk therapy” more than they are able to now due to the state of managed care. Their landscape has certainly changed in the last 30 years. My father is a psychiatrist in private practice who happens to still see fee for service patients doing psychotherapy – but he is a lucky one.

    This situation has certainly meant more psychotherapy opportunites for those of us LMFT’s, LCSW’s and other clinicians not in the MD category – which of course I, a MFT, find to be a benefit.

    One thing’s for sure – it’s a sticky situation all around.

  • Jim Hutt, Ph.D.

    Jim Hutt, Ph.D.

    August 18th, 2008 at 8:59 AM


    For those whose insurance will not cover, I discuss reducing the fee so they can afford it.

    Jim Hutt, Ph.D.

  • daniel brezenoff

    daniel brezenoff

    August 18th, 2008 at 9:10 AM

    Ally: Your question is a fair one. I tend to charge far less than most therapists and work on a sliding scale. Often I will work for the copayment amount, or close to it, meaning there are very few people I’d turn away for financial reasons. But of course, you can swtich this around: therapists who accept insurance must turn away those who don’t have health insurance, unless they can afford rates that usually exceed 100 dollar per hour. The bottom line is we all make choices, and I have chosen to stay away from managed care in my private practice in order to be able to provide treatment outside the medical model. It’s what I need to do in order to feel in integrity with my values and beliefs. I have a high level of commitment to serving as many people as possible, but I do have a limit. For those who must use their insurance (and you don’t mention people who lack both insurance and the means to pay privately – what about them?) there are many areas providers to choose from.

    Lisa, I agree it’s sad when a psychiatrist cannot offer talk therapy. On the other hand, couldn’t that psychiatrist choose to offer talk therapy and accept a private fee that is affordable to his or her patient?

    It seems in any case that we are all in agreement the current system is in dire need of major reform. Patients and professionals, not lawayers and for-profit insurance bureaucrats, ought to collaboratively run the system, right?

    It’s going to be a long, hard slog.

    Thank for reading everyone! I greatly appreciate your comments.


  • Jim Hutt, Ph.D.

    Jim Hutt, Ph.D.

    August 18th, 2008 at 4:01 PM

    Daniel: I really appreciate your comments–I have not accepted the insurance stuff now for about 15 years, and have have found a way not to turn anyone away who wanted to work–the only exception I have made is that I will not see someone or a couple or a family for no fee–they have to pay something. While barter is against the code of ethics now (it wasn’t always), a part of me wishes it wasn’t. You know, like the old days, so to speak, in medicine. “Can’t pay your bill? Fine, how ’bout I take that chicken over there?”
    That is one of the many things I am proud of as a clinician–I can decide to take a fee of any amount, no matter how small. And I do, even though it pisses off some of my local competition.

  • daniel brezenoff

    daniel brezenoff

    August 18th, 2008 at 5:45 PM

    Jim: I recently had a client offer me a gift certificate to a restaurant (one I really like!) in lieu of her payment, as she is not working and often short on cash. I declined. I told my wife about this; she loves that restaurant, too, and was none too pleased (but still supportive of my stance)! This got me thinking (an unhappy wife ought to get any husband thinking), and I decided I’d better re-read the NASW code of ethics on barter. It’s nuanced:

    “Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers’ relationships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client’s initiative and with the client’s informed consent. Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship.”

    The only part I wasn’t sure of is “accepted practice among professionals in the local community.” I can imagine a majority of social workers ‘accepting’ an occasional barter for an item that is not a significant object (family heirlooms, a car, etc) if it meant the difference between a client getting or not getting a service, but I’m not certain about it, so I’m glad I declined. Still, I think we have some flexibility there.

    Thanks for reading and writing!

  • Abigail


    August 20th, 2008 at 2:54 AM

    I know you would hate to turn away those who obviously are in pain and are hurting but do any of you ever make community referrals where someone could get help for a fraction of the cost or perhaps even free? It seems so senseless that someone cannot get the care they neeed because of a lack of money.

  • Jim Hutt, Ph.D.

    Jim Hutt, Ph.D.

    August 20th, 2008 at 7:52 AM

    Abigail: Absolutely. That said, however, our community/county resources have been seriously affected by budget cutbacks, and so forth, so that has been a problem. But as I said above, I will continue to work for significantly reduced fees.

  • daniel brezenoff

    daniel brezenoff

    August 20th, 2008 at 7:13 AM

    If someone cannot afford by lowest rate (generally, 40 dollars an hour, which is really quite low) I will certainly direct them to community services. But if someone wants to pay me 40 when they could go down the street for free, I won’t talk them out of it – unless their judgment is impaired by mental illness. Otherwise, I honestly believe I will provide a better service than the dear, beleaguered folks down at County Mental Health, and the money is well-spent.

    Hope I’m answering your question.

    Thanks for reading.


  • Michael


    August 21st, 2008 at 3:00 AM

    I guess I am like so mnay others in that I am just now beginning to realize what a stranglehold managed care has had for so many years on our healthcare system. I do appreciate the fact that therapists such as yourself are willing to work with patients to meet their needs when insurance options fail you both, and I hope that there are just as many others in other medical fields who will soon begin to realize the need to do the same. It is only when we start to hurt the insurance companies financially by pooling our own resources that real change can be made in this area.

  • AMH


    August 24th, 2008 at 7:32 AM

    Don’t you think that this takes some of the professionalism out of the talk therapy genre as a whole? That now people perceive the only cures to be those with medicinal intervention?

  • Clark W

    Clark W

    August 26th, 2008 at 3:09 AM

    There are some who feel that way about everything. For them the easy fix is always a prescription.

  • daniel b

    daniel b

    August 26th, 2008 at 10:26 AM


    I don’t know. Maybe. I think many people do turn quickly to drugs, and may disparage the ‘talking cure’. On the other hand, my experience has been that there are many, many people who are not interested in pharmacological treatment, and want very much to talk things through and do that noble work. (And some of them may actually benefit from medications, and do themselves no service in refusing to consider that path.)

    I don’t think talk therapy is in danger.

  • Libby


    August 30th, 2008 at 3:08 AM

    Thank goodness! Because I often feel that the best way to resolve most issues is to just talk about it and get it all out in the open. That is not to say that medicinal intervention cannot be of help to some but I do not in any way think that it is the end all and be all.

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