DRUG THERAPY PAYS. TALK THERAPY COSTS and is often being tossed.


The choice facing psychiatrists and mental health professionals is on its way to creating a nation with an increase in mental health problems and leaving us little faith in our entire system of health care.

When I first began treating patients in the early 1980’s, I thought that talk therapy was the best way to go.  Then, as I became a more seasoned therapist, it became clear that psychiatric medications were often very helpful (if not necessary) when given in small doses for those with difficulty reacting to current life stressors and particularly for those suffering from major depressive disorder, on-going panic attacks, bi-polar disorder, and the like.  I began working with psychiatrists and psychopharmacologists whom I knew had reputations for never over-medicating, and have since then offered this combination of talk therapy along with medication, when medication is indicated.

Fortunately, I am not alone in the psychiatric and therapeutic community.  Most of us agree that the combination of both therapy and medication is the preferred path to well-being.

Drug therapy alone – though a quick, expedient fix – is never, in my opinion, the best treatment.  I am particularly disturbed by the fact that family physicians have at their disposal samples of heavily advertised anti-depressants, which they hand out too easily and too often.  Drugs have different properties and different side effects.  Not following a patient weekly to note objective changes and/or effects is doing them a great disservice.

In order to allow patients to lead stable, productive lives, treating some patients with talk therapy alone is often sufficient.  Other times, medication coupled with having an on-going therapeutic relationship with a qualified professional is optimal.

Perhaps, having said that, you will better understand my reaction to Gardiner Harris’s March 5th article in the New York Times.  The title, in fact, should give it away: TALK THERAPY DOESN’T PAY, SO PSYCHIATRY TURNS INSTEAD TO DRUG THERAPY.

Harris focuses in particular on one psychiatrist’s confessions of only prescribing medication after a brief consult with a patient and no longer offering talk therapy.  This is all in contrast to his training at one of Chicago’s prestigious medical schools where upon graduating he started a psychotherapy (talk therapy) practice in 1972.

Until the last few years, in fact, he treated roughly 50 patients a week, some even twice a week. As the article reports: “Now, like many of his peers, he treats 1,200 people in mostly 15 minute visits for prescription adjustments that are sometimes months apart … often not even able to recall the names of his patients, when before he knew their inner most lives.  Then his goal was to help his patients become happy and fulfilled; now it is just to keep them functioning.”

That was definitely the line that made my anger soar.

We all have choices to make.  Psychotherapists as well as patients.  Yet, the article (with its many statistics) made me believe that we are, indeed, turning into a nation where even when people are being helped, the goal is to help them to be merely functional.

Think of all the CEO’s who expect workers to perform at peak levels.  Yet, it’s common practice to fire workers for not meeting company standards, because all they are doing is “functioning.” Functioning means showing up on time, staying the entire day, but remaining only on the surface of full productivity and never realizing their full potential.

We all know of such stories.   We also know that decisions made by health insurance companies and the government are ones that are made in large part due to ignorance and ill-advised priorities, all of which put our health at risk.   On the one hand, psychiatrists are being convinced – such as the one cited in the Times – to change priorities.   Clearly, listening to patients talk about their problems, developing a trusting relationship with them and helping them to process their options is no longer sustaining his practice financially.  He, like many others, is choosing to simply medicate.  Worse still, psychiatric hospitals that once offered patient’s months of talk therapy now discharge them within days, with prescriptions for medications in hand.  This is shoddy medicine and speaks to the heart of the matter: quality of treatment versus ignorance and greed.

I don’t wish to spend time judging doctors who choose not to take financial losses and opt only to prescribe.  Each of us has to live with the life style of our choice.  The professional decisions we make throughout our lives also have to resonate with what is important to us.  Yet, the great majority of we therapists who continue to offer talk therapy are not psychiatrists.  We cannot, therefore, medicate, and in continuing to see patients, many of us do so at a cost.   For those of our patients who have no coverage, we allow them to pay whatever they can.   For others, we offer a sliding scale and hope that those who pay in full will help cover our costs.  When it doesn’t, we end up compromising too much of our income, and our financial burden then becomes a real stress in our lives.  As I see it, there’s something very wrong with this picture.

Those in government who are making public policy as well those in the health care industry who dictate the number of allowable visits do so, more often than not, with no understanding of the dangers involved in ceasing treatment.

Unnecessarily long hours are spent by providers attempting to justify, for instance, why someone who has expressed suicidal thoughts is at high risk.  What they refuse to accept is that if therapy is discontinued due to lack of coverage they (the insurance companies) will be paying much more money for repeat hospitalizations.  But none of that seems to matter.  Theirs is a business first and foremost.  For those of us needing to deal with their representatives, it is apparent that most seem to have little understanding of psychiatric disorders.  They are spokespersons (gate keepers) for a business.  The business just happens to be  “health care.”

As providers we believe that psychotherapy is a microcosm of all human relationships.  The inability to navigate and understand relationship issues and the effects of early life trauma is – through a relationship of trust – explored and, when most successful, resolved during talk therapy treatment.

Talking and processing life events is instrumental in helping people to heal and to develop new ways of behaving, developing better coping skills and gaining an awareness (if not total insight) of how their behavior effects others and how others effect them.   Without that, no amount of pill taking will allow people to alter their expectations, understand how best to improve the quality of their life or their work.  We will, instead, become a nation of robots whose wiring may be somewhat less taut, less liable to explode, but we will certainly not be better able to live richer, fuller, happier lives.

What will it take, I wonder, for those in positions to change the system, to make the mental and physical health of our people once again a top priority?


*Visit my website at http://www.applemanshapiro.com/ to learn more about my psychotherapy practice, my work as an addictions counselor and oral historian and my book, FOUR ROOMS, UPSTAIRS, which may be purchased directly from the site with no fee for mailing.