Wednesday, July 21, 2010

Carlat's View of Psychotherapy

So I finally got a chance to listen to Daniel Carlat's Fresh Air chat regarding the ills of modern-day psychiatry. I very much enjoyed the radio show, but I do take issue with the idea that every psychiatrist should be providing psychotherapy to all of their patients (which was implied, though not explicitly stated). I take issue with this because I have deep respect for psychotherapy -- the many forms, the training and experience required to do it well, and the relative specialization necassary to do it well. Carlat seems to be saying that psychiatric patients everywhere would be better off if their psychiatrists just 'did some psychotherapy' with them. He seems to be missing the point that there are dozens of kinds of psychotherapy, each indicated for particular kinds of patients and problems. He could spend years in CBT training, for example and still not be well suited for tackling certain kinds of borderline phenomena, for example. Further, it is not clear that Carlat is serious about providing full courses of psychotherapy, suggesting that he thinks he can provide solid therapy in 30 minute sessions. I think he'd be hard-pressed to say that a 30 minute psychotherapy session, for anything but the most rudimentary supportive therapy, is standard of care. This take is an interesting reversal of the idea that psychologists should not have prescription rights. Psychiatrists mostly think that psychologist prescribing will entail a glossing-over of very serious psychiatric and medical issues that create/exacerbate and co-occur with depression. I do think that psychiatrists should practice psychotherapy when they want to and use the very specific forms they feel competent to provide. This will necessarily include a need to keep-up with the literature, just as psychiatrists must keep up with the biological psychiatry literature. I bet that Daniel Carlat is not reading the psychodynamic, CBT, etc journals regularly.

To all the psychiatrists that want to practice psychotherapy, amen! I just recommend that you choose a style and become expert in it. Don't try to be all things to all people.