Health care costs are exploding, and one silent factor in containing costs is rarely mentioned: the underutilization of psychological services. The evidence is clear and has been for three decades. Studies have suggested people who see psychologists for symptoms are less likely to utilize medical services.
In other words, mental health treatment saves a lot of money.
But the problem goes deeper. As psychologists, we need physicians to refer patients to us in order to help them. Fortunately, many do. But when physicians refer patients for psychological consultation or counseling they often do so by staying within the confines of their own model of disease, their own "box." What are the instructions of that box? Reduce specific symptoms, as fast as possible. Thus, referrals are characteristically directed to psychiatrists or cognitive behavioral therapists. Cognitive behavioral therapy (CBT) is appealing to medical professionals because the approach makes intuitive sense, is relatively easy to understand and is very consistent with the medical model. Patients are provided with education and given homework, which is not unlike what doctors do: tell people about their disease and expect them to be compliant.
Sadly, referrals for cognitive behavioral therapy do not benefit as many patients as you might believe. Cognitive behavioral therapy is great as long as you are one of the 20 percent of patients who benefits. Because CBT trials often include only patients with one disorder (such as depression without a co-existing anxiety disorder) they exclude patients with more complicated symptoms. A large percentage of people in the mental health population meet criteria for more than one diagnosis.
Patients experience illness, not disease. Illness means that symptoms alter relationships, sense of self and the possibility of future planning. What illness means to a patient is deeply impacted by how dependence was tolerated, and if care and support were offered throughout the patient's life. The meaning of experience is what psychodynamically-trained therapists focus on. These therapists, of course, are deeply concerned about the reduction of symptoms, and they address how patients cognitively assess their problems and symptoms. But psychodynamic treatment's effectiveness is broader and deeper in scope, which is why it has been found to be longer lasting in many studies. Another 2011 study, as reported in Journal Watch found that psychoanalytic approaches were more beneficial at five years when compared with short-term approaches.
What we need is for physicians to ask different questions about illness: Why is this person so hopeless that he can't even take in my treatment recommendations? What does it mean to her that she will experience partial, not total recovery? When these questions are asked, the physician will likely consider a referral to a well-trained psychodynamic therapist. Psychodynamic approaches are increasingly demonstrated to be superior when dealing with complex emotional problems.
We don't think that physicians should have to map the referral territory alone. We also do not think that CBT approaches are not useful or should be discarded. In fact, one of us has argued that psychoanalysts integrate cognitive and behavioral approaches into their practices! We do think, however, that it behooves a major organization of psychological clinicians to delineate the signals and signs of the need for psychological referral. In other words, what the press has delineated as "evidence-based treatments" has misled a lot of physicians and patients who are looking for help, because while CBT is useful for many symptoms, people who have complex problems (including illness) often do not have the internal resources to benefit from many short-term approaches. Both patients and physicians should be empowered to consider all kinds of psychotherapeutic options when dealing with illness.
Patients today know that illness is complicated. They search the web for alternative explanations, and they seek out the help of alternative practitioners. Maybe we should ask why it is that patients feel so alone and on their own to seek out their own treatments and medical advice.
Physicians can help patients feel less alienated by working collaboratively with psychologists who think about the illness experience from a comprehensive and multi-faceted perspective.
The reality is, well-trained psychologists and those with analytic training can be just what patients need. Physicians just don't have the time to do what psychologists can do. Often, though they appreciate the concept, they do not have the training to help people understand how the mind and the body interact in the face of illness.
This article was co-written with Mary-Joan Gerson, Ph.D. Dr. Gerson is faculty, supervisor and director of the Advanced Specialization in Couple and Family Therapy, N.Y.U. Postdoctoral Institute in Psychotherapy and Psychoanalysis, Private Practice, N.Y.C.
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