An  American  training program for mental health professionals in China provides classes via telepsychiatry (via video conferencing ) but many of the trainees wish to have their own therapy by experienced therapists who are in quite short supply in China at this time.

There are highly functioning productive people in the United states who are in occupations and jobs which often take them out of town or have long commutes to work with irregular work hours. This situation makes it quite difficult for them to arrange  psychotherapy with experienced psychiatrists  which would require them to come for sessions at least once per week.

During the past year I have become involved with devoting part of my practice to telepsychiatry and am now offering therapy in each of these three situations.

When I agreed to provide treatment one morning per week to the above mentioned clinic I already had experience in teaching courses online with video conferencing but I had not treated patients with this modality. I knew that some of these patients might have complicated mental illnesses which would require complex medications and that some might have to be hospitalized. I was aware that certain paranoid patients could be suspicious of electronic communications and some patients might require a translator if they did not speak English. I was pleasantly surprised to find how smoothly everything was able to run. A mental health nurse is in the room with the patient and a translator was available when needed.  The patients understood the concept that they were being seen by a psychiatrist in another city via video communications. We had a clear face to face discussion and the patients seemed as comfortable as in any other setting in bringing me up to date on their symptoms. I had access to a very sophisticated confidential electronic medical  record where I could record my findings and check the observations of any other visits that the patient had at this clinic. I could refer the patient for lab tests as well as to a primary care physician. I also could make referrals to other mental health professionals connected to this clinic who could do individual, family  or group meetings  with the patient. I prescribed medication directly through a very efficient electronic prescribing system, which electronically connects to every pharmacy in the state. If needed I could alternately fax a prescription or make a telephone call directly to the pharmacy. On the few occasions where a patient needed an immediate hospitalization I could arrange that and provide the referral information needed by the admitting doctors. It has been a very gratifying experience to spend this time providing this needed service.

First CAPA Graduation in Beijingi

For the past year I had been teaching as part of  the Chinese American Psychoanalytic Alliance (CAPA),a very innovative program  founded by a friend and colleague Dr. Elise Snyder.This program uses video conferencing mostly by Americans who provides high quality training to mental health professionals in China who previously had very limited access to this type of training. The program has grown and become quite in demand by young Chinese professionals embarking  upon a career in providing mental health treatment in China. One year ago I participated in study tour to China with CAPA where I had an opportunity to give a few lectures and also witness the first graduation from this program which was held in Beijing. In conjunction with such training, it has been common for the trainees to arrange their own personal therapy. Unfortunately for a variety of reasons, there has been a lack of therapists  who could offer such treatment to the trainees in China. Many of the Americans who have been teaching in this program have offered to treat such a Chinese trainee via telepsychiatry ( video conferencing) as did I. Due to the wide disparity in income between Americans and most Chinese, such treatment has to be offered at fraction of the usual fee received by American therapists in the United States. The trainees usually speak English quite well but there are at times interesting challenges related to the nuances of the meaning of words as well as in understanding various cultural differences. The fact of there being a “ one child policy”  in China means most of the trainees have grown up as an only child which has important psychological significance. Most Americans are not familiar with the Chinese concept of “shame” which reassembles but is quite different than “depression” which can be an important part of the childhood experience of growing up in China. Participating in this program as a therapist has also been a gratifying and interesting experience which I am pleased to continue.

The third situation which I described above, reflects an anticipated  shift in the  attitudes of many Americans towards  technology and psychotherapy. This change, I believe, is taking place in both patients and therapists. I practiced psychiatry in Manhattan as well as in a suburb of New York City  and more recently now in Los Angeles. I have seen  many sophisticated patients who chose their psychiatrists by referrals from trusted physicians or friends and would rework their schedules to make regular sessions, often in the early morning or evenings. People tended not to change jobs very often and it was common to have an entire course of  therapy with one therapist. Now days people commonly choose their psychiatrists after a careful investigation of their credentials and background online. Since the Internet is used for obtaining other important information it seems natural for  so many people to rely on the Internet and feel comfortable in evaluating information available on it. It is a known fact that people are changing jobs much more frequently, even in  higher paying positions. Therefore, one can’t be confident that a therapist in one location will be convenient to see at a later date. It seems that time is even at a greater premium than it was in the past. Commuting time is longer especially in a city such as Los Angeles and work environments frequently require people to be quite flexible. This means working at home at times, traveling when needed and irregular hours. Certain occupations such as the entertainment industry in Los Angeles requires long periods of time out of town as does pilots and airline personnel to name just a few. There is  increasing comfort with modern technology illustrated by  the growth of the use of video conferencing in business and education and the personal use of texting, Skyping , Facetime etc. Therefore it is inevitable that there will be a shift in the practice of medicine to use more telemedicine and for psychiatrists to use increasing amounts of telepsychiatry.  Therefore, I was very interested when the California Telepsychiatry Group (also now American Telepsychiatry) ,who were running the services for the mental health clinic described above, asked me if I would be interested in devoting some time to seeing private patients with their group.

I spent some time talking with their Director Dr. John Schaffer and I was impressed how they have arrange their video conferencing, electronic records and electronic prescribing to be HIPPA compliant (meaning state of the art confidentiality techniques) . They had addressed the various legal, ethical and questions of malpractice insurance and were carefully vetting the psychiatrists who would work with them. In addition they set up a very novel and interesting “meet and greet system” where potential patients, at no cost, could have a preliminary 10-15 minute   telepsychiatry meeting with any of the psychiatrists available for treatment . They could therefore review the credentials and experience of potential therapists, as well as meeting them, before they decided to enter into treatment. I am very pleased to now to be connected to an entity which I believe is on the cutting edge of a system for providing quality psychotherapy with this modality.

I suspect in 10 years from now or less,  people will look back on the three examples which I described above and see them all as every day occurrences in the delivery of mental health services in this country and throughout the world.

Fast forward to the present. A few years ago I set up a new private practice in California where I have relocated. Patients are still referred by the usual sources but in addition the Internet has made it a whole new ballgame. Finding doctors on the Internet has become a common practice. I have a professional website and it is not unusual for people to find me through several Internet sources. They have reviewed my web site and also googled me. They are aware of books and papers that I have written. They have seen my Facebook page. They may have even read my movie review blog. Having an unlisted personal phone number is not necessary since I have had a home office for more than 20 years, originally in Scarsdale New York and now in Woodland Hills, California. It doesn’t take much skill to locate my home address or even my email. People can check my credentials online and find out if complaints have been made against me and even make comments about me online. They probably can find out more about my family members than I know. Why would they want to do that and in fact why was I trying to be anonymous in the first place?

There are a couple of reasons why a psychiatrist might want conceal his or her private life , particularly one that does psychoanalytic or psychodynamic therapy. It is well known that a patient’s thoughts and emotional reactions to his or her therapist reflects important psychological insight into themselves. Therefore it is often the goal of a therapist to try to provide a gray or blank screen of themselves in order to make it easier for the patient to project or imagine things about the therapist. This would facilitate the formation of “transference” which is an extremely important part of psychoanalytic and psychodynamic treatment. The more the patient knows about the therapist, the less the transference originates with themselves and the more it is based on reality. While there is no doubt in the validity of this type of thinking, it is also true that just knowing some factual information about the therapist does not eliminate the development of transference. Experienced therapists can help the patient understand the meaning of their curiosity and whatever they have learned from the Internet about the therapist. Just knowing about the therapist’s life doesn’t mean that you have lost the opportunity to have transference be a vital part of the treatment. The patient’s interpretation and emotional reaction of the information that they have learned becomes useful data for treatment.

There has always been a concern that a patient might stalk a therapist after finding out where he or she lives or perhaps call or email the therapist  (other than for administrative reasons). This might be precipitated by a strong emotional attachment or perhaps because of delusional ideas. While this may not be prevented in rare situations, it is the task of the therapist to help the patient to understand the boundaries between them and the value of discussing any such tendency in the treatment sessions.

Modern day technology offers much more potential benefits than obstacles to good mental health treatment. Information about the credentials and experience of therapists, education about mental conditions and various forms of therapy as well as information about psychopharmacology are available online. The state of the art now even makes it possible to provide therapy in locations where it hasn’t been available via Internet video technology. People who travel a great deal and where it is difficult to commute for regular therapy sessions  may be able to use this modality. There are also many locations where trained therapists are in short supply. I have had some experience with telepsychiatry and I shall blog about it more in the future.

Recently we saw a new movie which is going to be released this week in Los Angeles and New York as well as across the country shortly thereafter. Aside from it being an excellent film which will probably get some Academy Award consideration, I believe that it will make an excellent teaching film for mental health professionals who are studying manifestations of grief. I will reproduce our review of it and then add a few additional comments :

The Rabbit Hole – Rating 4/5 stars

David Lindsey–Abaire as screenwriter for this film, based on his own play, really gets into the head and the emotions of two grieving parents 8 months after the death of their five year old son who died running after his beloved dog. We never meet Danny and barely see a picture of him but we come to clearly understand the relentless pain in all it’s forms which his parents Becca (Nicole Kidman) and Howie (Aaron Eckhart) are feeling. Each of them are  grieving in his and her own way which despite sharing this most personal tragedy and a good previous relationship, there seems to be  no room for empathy between them. Becca’s quest to find some way to deal with her deep dark feelings leads her to establish a relationship with Jason (Miles Teller), the 18 year old high school senior who swerved his car, which he confesses to her may have been going a mile or two over the speed limit, which led to the tragedy and  now has created a bond between them. Becca’s somewhat religious mother (Diane Wiest) whose son died at age 31 , eleven years previously, provides a counterpoint from where she is coming. Nicole Kidman who saw the original play and started the ball rolling to make it into a movie chose John Cameron Mitchell to direct it. Mitchell and Lindsey Abaire who were guests at our screening acknowledged that they complemented each other as they explored the fine points of this film. The director, who had only a 4 million dollar budget, shared with us that he let the actors steep  themselves into their emotional  roles which he appeared to nimbly direct as well as spending  a great deal of time in editing the fine points. He gave a touch of humor to   a primarily a dark movie and kept us the audience observing at a slight distance from the unimaginable tragedy. We did not shed a tear for the young boy who we did not meet or really know. As mental health professionals who have worked with many grieving patients, we had the feeling that we were empathizing with people we cared about, as we might with a patient who is   involved in their own dynamics that are unfolding before us at somewhat rapid pace. The fact that the writer, director and the actors really nailed the complicated feelings and interactions without ripping apart the guts of the audience (which they could have easily done) may be judged a shortcoming of the movie by some or the height of sophistication by others.

This movie also merits comparison with four other movies which we have seen in the past year and each of which shows attempts at dealing with grief in a different manner.

A Single Man shows Colin Firth in an Oscar nominated performance as George a college professor whose lover has died in an auto accident and in his grief he is on the verge of suicide when he meets a young student who cares about him. Robin Williams does an excellent job as an unsuccessful writer in World’s Greatest Dad grieving   a teenage son who committed  suicide. The father pretends his late son has written the story of being bullied and the result is a game changer for the community and for the dad which gives some meaning to this tragic loss.  The Lovely Bones deals with the murder of a young teenager (Saoirse Ronan) who had just begun to feel the glimmers of romance which leads the audience to feel her parent’s unresolved grief despite the youngsters ethereal existence. There is a small amount of compensation as the killer is caught through the efforts of the girl’s sister.  The film, which most closely resembles the Rabbit Hole, is The Greatest which brought together a comparable great performance by Pierce Brosman and Susan Sarandon who are the grieving parents of a teenager killed in car accident while he is with his girl friend played by Carey Mulligan. The potential for the parents to live with their grief is the unborn child being carried by the young girl friend whereas  in the film which we reviewed today,   the hope for a better future is only hinted by a subtle but important gesture at it’s conclusion. We thought these two were both excellent films The  Greatest didn’t achieve the critic’s Oscar acclaim and it appears that the Rabbit Hole may get some such bids. However overall, we rated the Rabbit Hole a notch lower. We certainly do believe that  this movie is the finest example and should be used as a teaching tool and stimulus for discussion for those who are studying the grieving process as well as a movie worth seeing for anyone interested in these all too real human emotions

Additional  Comments

To experience the death of your young child is one of the most painful, difficult and traumatic events that a human being can go through. Mental health professionals who have studied this event have recognized that the subsequent grieving has certain characteristics that go beyond and are somewhat  different than the usual emotional responses that are seen after the death of a close friend or relative. It has been labeled as  complicated  grief and this term includes other circumstances in addition to the loss of child, such as the death of an adult or child  by murder, suicide, unusual unexpected trauma such as terrorists attacks ie 9/11, etc.  While the loss of a close person is rarely forgotten, there often is a gradual resolution of the intense feelings over the course of a year with amelioration of most of the symptoms such waves of sadness, episodic crying, insomnia, intrusive thoughts, occasional hallucinations, intense anger, etc. Most people who grieve usually do not find it necessary to have counseling or any form of therapy.With complicated grief such feelings rather that resolve often intensify in the months following the loss. There may be evidence of major depression with weight loss, continued insomnia and even suicidal ideation. There can be a resort to heavy drinking or drug use. There can be intense anger, not only at self but at others , often with a demand of some type of restitution or revenge. Relationships are greatly strained and marriages often are not able to withstand this trauma. Psychotherapy is often helpful with or without medication. Sometimes a group process is used which includes other people who have gone through similar losses.   It may be useful for some type of a memorialization process to be developed where the memory of the lost person is perpetuated in some worthy fashion. The above movie certainly did not touch upon most of these issues but it did clearly show the impact on the parents of the traumatic loss of their child. The subsequent behavior and the emotional responses of each of the parents were very real and plausible in view of the loss that they had suffered. As I noted, this film would be an excellent starting off point for professional students to discuss and analyze the grieving responses in this very difficult situation. Obviously the movie gives the viewer a certain cathartic experience and you can also appreciate it as a very good creative artistic accomplishment which may be viewed by many as one of the best films of the year.

A few years ago I heard about a resident who presented the following case to his psychotherapy supervisor. (I have changed some details for confidentiality):

Case History

The patient is a  22 year woman who is working as a nanny for a  prominent celebrity. She entered twice per week psychotherapy two months previously because of difficulty in relationships with men. She has just started to talk about how she was physically abused by her alcoholic stepmother as a child. During a recent session she appeared to be distracted and wasn’t her usual organized self. Near the end of the session she blurted out that she became very angry with the 18-month-old child that she cares for and slapped the child . She was scared she might have hurt the child but he seemed to be OK. The therapist was stunned and for the first time was at a loss for words. The patient changed the subject and spoke about another subject and then the time was up. Her parting words were that she was really glad that the therapist didn’t condemn her. She knew that she did the wrong thing with the child and will try not to do it again. She added that if the therapist had reprimanded her, she never would come back again. She feels she can trust the therapist and is now very hopeful about getting help in therapy.

What Would You Do?

Before you read further, I would like to suggest that you jot down on a piece of paper if there is anything that you think that the therapist should do. Then let us see if the discussion below changes or supports your approach.

Mandatory Reporting of Child Abuse

It is well known that the there is a bond of confidentiality between a patient and a physician which is recognized by the law. This also extends to other licensed therapists, clergy, and attorneys. Recognized confidentiality is the keystone of our ability to do psychotherapy. Patients understand that they can trust us with their deepest secrets.

In fact our patient was initially concerned about talking about her stepmother because she has a 17-year-old sister at home and she didn’t want any repercussions to occur to her stepmother who she feels has been good to her  despite the  episodes of abuse when she was younger.  Most people have awareness that a special court order by a judge is required for a doctor to turn over medical records without permission of the patient. There are situations where doctors have even refused to do so even after such a court order and have faced the consequences. In this particular case there is obviously no court order. However there are some other reasons that the psychiatrist might feel compelled to break his patient’s confidence.

In some states including New York where this patient was being treated, there is a law, which mandates physicians to report any known or suspected cases of child abuse. When such reports are filed, there would be a case file opened and an investigation is supposed to be immediately conducted. In such a case the parents who are obviously responsible for the child would be questioned to determine if they have put the child in any jeopardy. It would seem that in such a case the parents would be informed that a physician has reported suspected abuse and would obviously act accordingly.

The Tarasoff Rule

On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff. Both had been students at the University of California at Berkeley. They had met a year earlier and  Poddar became convinced they had a serious relationship. Tarasoff told him she was involved with other men and not interested. Poddar became depressed.He talked to a friend and was eventually convinced to go to student health. He started therapy with a psychologist on staff. During his his ninth session, Poddar confided to his therapist  that he was going to kill Tarasoff when she returned from summer break. The therapist subsequently informed the campus police that he felt Poddar was dangerous and that he should be hospitalized involuntarily. The police picked up Poddar, but after questioning felt he had “changed his attitude” and released him after he promised to stay away from Tarasoff. Poddar stopped thaerapy and later went to Tarasoff’s house and stabbed her to death with a kitchen knife. He then called the police and asked to be handcuffed. Her parents then sued the psychotherapist for failing to warn them or their daughter about the danger. The California Supreme Court rejected the psychotherapist’s claim that he owed no duty to the woman because she was not his patient, holding that if a therapist determines or reasonably should have determined “that a patient poses a serious danger of violence to others, he bears a duty to exercise reasonable care to protect the foreseeable victim of that danger.” Many states including New York  followed California’s lead and now have expectations of a “duty to warn” potential victims. Under the Tarasoff Rule a therapist, therefore, does not incur any liability for breaking confidentiality to warn a victim who is in danger and is expected to do so.

Involuntary Hospitalization

If the patient were to have a serious mental illness such as severe depression with suicidal ideation or psychosis with command hallucinations, the psychiatrist could fairly  easily arrange an involuntary hospitalization for further evaluation and treatment. This apparently is not the situation in this case.

What Could Happen?

If the therapist attempted to do a Tarasoff warning, let us consider how this would work. First of call she would have to know how to reach the parent of the child to warn them. She wouldn’t necessarily have that information. In this case since the parent was a celebrity she might have some clues, but such attempted warning would no doubt involve some intermediary parties prior to speaking directly with the parents. This might involve publicizing the concern and the abuse, which might even end up in the media. This could embarrass the parents although one would think they would want to know. However, if the actual danger were exaggerated, then this could be creating bigger problems.

If the therapist were to submit a report of suspected abuse as mentioned, this would trigger an investigation, which would involve the parents. In the same way if the therapist had called the police and reported a potentially dangerous situation, the police would track down the nanny who could be caring for the child. They would have to take the child into protective custody until they located the parents  (who sometimes are out of town). Then they would turn the situation over to an agency which would investigate potential abuse.

As all the above were considered, the therapist also had to consider the strong possibility that any of above actions would most probably lead to the termination of therapy. In addition the patient who had resisted entering into psychotherapy in the past, would be further alienated from seeking help.  She would most probably obtain employment as a nanny in the future even if she didn’t have a letter of recommendation from her current employer. She interviews very well and actually had a letter of recommendation from a previous employers that would only show a two-month gap. She would then be in the same situation to potentially harm children with no one who would know about it. It is unlikely that there was sufficient evidence to support any charges being brought against the nanny that would lead to her being put in jail or hospitalized with a mental disorder.

On the other hand, the nanny could have seriously injured the child and there is an obligation to that child and any future children under her care.

What Did Happen?

The therapist ultimately decided with the assistance of the supervisor that she would not take immediate action which would lead to the patient leaving therapy and thus lose any chance of preventing this young women from abusing children in the future. During the next session two days later, she brought up the subject of her hitting the child. The patient said that she hadn’t done that again. The therapist said that she  was pleased about that but she shared the dilemma that that she would be obligated to warn the parents if she believed the child was in danger, as well as have to report abuse. She suggested that the nanny take a leave of absence for few weeks from her work which was easy to do since there were other nannies who also cared for this child . She was able to take on work which she had done before assisting elderly people where the patient had no inclinations for abuse. They agreed they would work on this problem and in the future they could decide when she was ready to return working with children. The patient was receptive to this idea and appreciated the concern of the therapist in wanting to help her and yet not get her into trouble, as well as understanding the legal and ethical obligations of the therapist.

Do You Have Any Comments On This Case

Your comments on this case are especially welcome since there is no easy answer here.

]]> http://www.psychiatrytalk.com/2010/10/when-a-nanny-abuses-a-child/feed/ 2 http://www.psychiatrytalk.com/2009/11/happy-65th-birthday-your-psychotherapy-fee-is-reduced/ http://www.psychiatrytalk.com/2009/11/happy-65th-birthday-your-psychotherapy-fee-is-reduced/#comments Wed, 18 Nov 2009 20:47:55 +0000 Dr. Blumenfield, M.D. http://www.psychiatrytalk.com/?p=302 Today: 65^th Birthday While in Psychotherapy

Tomorrow: Will Psychiatrists do Psychotherapy?

The Happy 65^th Birthday Conversation

I remember the first time I had the “Happy 65^th birthday” conversation with a patient. He was a very successful businessman and financial investor whom I had first seen in my New York practice about 15 years previously at the time he was having some personal and business crises. He was in twice week  psychotherapy with me for about three years. When he was 62 his wife died and he came in for a few sessions during this difficult time but handled his grieving as well as could be expected. He came back to see me two years later related to conflicts within himself and with his children about a decision whether or not to get married to a women with whom he had a relationship for about 6 months. I saw him once per week and as I expected, he was working well in therapy.

Your Fee is Reduced

I knew his 65^th birthday was coming up and when he came in and announced it was his birthday I replied, “Happy Birthday and your present from me will be that your fee will be reduced 150% to about $100/session”. I elaborated that this was the Medicare fee for 45-50 minute psychotherapy sessions.  He laughed and said, “Of course not, I am more than glad to pay your full fee and you know that I have no trouble affording it.” He was quite surprised when I told him that would be against the law and that I was mandated to charge him the Medicare fee. He offered to pay the difference and thought it was grossly unfair to me for him to pay me a reduced fee. I told him that I had no choice and that the only way that I would be able to see him was to charge him only the Medicare allowable fee. Obviously, this became a topic in the therapy with him but that is not the point that I am discussing here.

Impact on the Psychiatrist of Treating Patients on Medicare

Over subsequent years as many of my patients aged, I had similar conversations with them. I had previously treated a relatively small number of patients on Medicare and was comfortable in accepting the reduced fees. While the fee for psychotherapy was much lower than my customary fee, the Medicare fee for psycho-pharmacology was only slightly below my usual fee and the time of these visits were 20-30 minutes per session. When I would see patients who had private insurance, most of their policies allowed them to see a doctor “out of network” which usually meant that the patient was allowed to make up the difference in payment of what their policy allowed for treatment and that of my usual fee.  I also had a major academic position so overall the Medicare portion of my income was relatively small.

While I could theoretically limit the number of patients that I would see on Medicare, I was not comfortable in choosing individual patients to treat using that criterion. Once I would agree to see a patient, as I stated above, I would be obligated to charge them only the Medicare fee. So as I always did,  I continued to accept Medicare patients as they came to me if I felt I could help them.

However, as the years progressed I was increasingly involved with other professional activities mainly research, special projects as well as eventually becoming the Speaker of the Assembly of the American Psychiatric Association. This meant that I had less time for private practice and therefore seeing patients on Medicare would have a more significant impact on my income.  There happened to be a brief period where I was not treating any patients on Medicare. Since it would not impact any of my current patients, at that point, I made a decision to do something that I thought I would never do. It was something that I understood an increasing number of psychiatrists and other doctors in New York, Washington D.C. Texas and I am sure other locations were doing.

The Opting Out Solution

I opted out of Medicare! This is a legal process where a doctor files papers with Medicare which states that he or she is no longer part of the Medicare program and can no longer submit bills to Medicare nor could any of his or patients submit your psychiatric bills to Medicare for reimbursement. In fact, patients had to sign a statement that they understood that neither they nor their heirs could be reimbursed for any bills that you had given them for treatment. I, of course could see any patient of Medicare age but they could only pay me out of pocket or be reimbursed through insurance that they might have other than Medicare. This worked satisfactorily for me as I had a limited private practice, which I also continued when I recently relocated to Southern California. I will always tell patients when they first call me for a consultation that I am no longer part of the Medicare program and the implications of this. Some find this O.K. and will see me while others will not.

I don’t believe that my particular decision to opt out or the decision of other psychiatrists to do likewise seriously impacted the availability of care in the two communities in New York and California where I practiced. As far as I could see, there still are sufficient psychiatrists accepting Medicare. Perhaps some were not offering psychotherapy to such patients but were there to do psycho-pharmacology, which is essential care for many conditions. Also, in these areas there are many psychologists and social workers who are trained in psychotherapy, many of whom have a fee schedule less than the prevailing psychiatric fees for psychotherapy. They often work in conjunction with a psychiatrist who prescribes medication. Such dual therapy, in my experience, usually works quite well. However, in some situations it is much more ideal that a psychiatrist should do the psychotherapy and prescribe the medication to an individual patient. If psychiatrists continue to opt out in these communities or in communities where there are limited psychiatrists, this could become a major problem.

Implications of New Changes in Our Healthcare System

We are on the verge of major changes in our healthcare system. Certainly I hope and expect that the coverage of mental illness will be on parity with other medical conditions. This should include inpatient treatment and outpatient follow-up care for serious mental illness, which includes substance abuse. It should also include psychiatric care for all designated mental conditions. It is possible that there will be limitations put on the number of sessions allowed for psychotherapy and on the fee schedules that are set up for this form of treatment. Ideally the fee schedule should be fair and equivalent to other medical care, based on the time that the psychiatrist spends administering psychotherapy for patients who need it. These are very complicated issues. While psychotherapy has been shown to be effective with evidence-based research, there may not be the same degree of established research as to the efficacy compared to some other medical conditions. This could lead to limitations or no reimbursement for psychotherapy of certain conditions. If the emerging system limits or  discourages psychiatrists from doing psychotherapy, this will be a great loss in providing mental health care in this country. The growth of psychotherapy has a history as coming from psychiatrists, along with our colleagues in the mental health field So many of the great therapists and teachers have been outstanding dedicated psychiatrists. If psychiatrists are forced to do less psychotherapy, there will be a diminution in training programs and psychotherapy research, which could be a great loss to the quality of care being delivered in this country.

I fervently hope that we make major changes in our healthcare system. I personally believe that there should be a public option even though I recognize the possible dilemma as I indicated above, that could occur for psychiatrists who wish to utilize their psychotherapy skills along with their other psychiatric treatment modalities. The best way to work this out is to continue to put a searchlight on all aspects of this issue. I hope that this piece will stimulate discussion that will allow us to continue to move forward and solve these problems.

Your comments are welcome.