The Case for Accountability in Clinical Practice

More Information on Psychiatry

We in the psychotherapy and counseling professions are often faulted for indiscriminately dispensing patient care, lacking data to defend the validity of our work. Presented in the case against us is that we rarely use, or even have available, much in the way of number-generating tests. Our medical colleagues, on the other hand, usually have plenty of data in the form of laboratory tests and radiology. Post-treatment follow-up in our profession also tends to be spotty.

Our usually unstated response to these accusations may be something like the following: "It's not our fault. Treatment past several visits is frowned upon by insurance companies, and is not likely to be reimbursed by them. Insurance rarely covers psychological testing and limits the possibility of reimbursement for follow-up sessions."

It would be lovely if we did not have to depend on insurance for payment. But, really, how many patients are willing to pay out of pocket? The answer may come as a surprise, but recent data suggests that the private pay option is on an upswing, as is payment for quality (Monitor On Psychology, 39, 2008, p. 46; APA Practice Organization report on Pay for Performance Conference, March 27, 2008). It is more commonly used than most of us might imagine. And, why?

Do you really know of many patients that can be adequately treated for anxiety or depression in the few sessions allotted by most insurance companies? How about producing lasting results? How often are they achieved through time-limited treatment? Perhaps substituting streamlined, cognitively and biologically based treatment for the old psychodynamic practice of endless, unmonitored treatment may be cost-effective. But the long-term results may well be disappointing and extended follow-up is so often missing from contemporary treatment studies. For example, in the massive NIMH-funded depression study STAR*D, follow-up at each trial stage was at most 12 months. (See A. John Rush, M.D., STAR*D: What Have We Learned? American Journal of Psychiatry 164:201-204, February 2007). Imagine a physician being satisfied with a report after six or twelve months of successful treatment of a cancer that returns in full force after a year.

Here is my antidote. I believe that my approach applies equally to run-of-the-mill psychotherapy patients and those with more complex psychiatric problems. Part of my practice consists of relatively standard psychotherapy patients and I was even trained years ago as a psychoanalyst. However, my interests have become dramatically broader. Now, I focus my practice on patients with complex, often long-standing, problems. These may be cases that other clinicians have given up on. My patients typically have a combination of symptoms, such as depression or anxiety, and difficulties involving family, children, relationships, or employment, and often one or more medical conditions. These issues tend to overlap and are frequently hard to sort out. My job -- regardless of the type of patient being treated -- is to work assiduously with the patient to find solutions to these problems.

My treatment protocol is described in my most recent book, Evidence From Within: A Paradigm for Clinical Practice. In the beginning of a case, I do a clinical evaluation and, as soon as feasible, get psychological or neuropsychological testing. I do this with adults as well as children. The feedback is used therapeutically according to the principles of collaborative psychology and psychiatry (Engelman and Frankel 2002, Finn 2007). I then create a report, outlining tentative impressions and a treatment strategy and plan. At this point the patient and I have an idea of what kind of clinical process he or she is agreeing to undertake. After testing, there is a trial period of several months when each proposed clinical strategy is evaluated for efficacy. Verbal or written reports, including modified treatment plans, are created successively in response to changes and progress in treatment, often at four-month intervals.

Now you may be thinking, So much trouble and expense, and for what?

Return for a moment, however, to the world of medicine. Would you really fault a physician who is meticulous about data, gets needed consultations, regularly informs patients about findings, and revises his or her treatment plan according to whether progress is occurring? Of course not.

So, which patients require this kind of approach? The demarcation between those that do and those that don't has more to do with the complexity of the case, as well as the willingness of clinician and patient to participate in such a treatment, than with diagnosis. Can the patient understand the need for taking such care with diagnosis and treatment, or are they satisfied with a brief, subjective assessment? How much difficulty have they had in the past getting an accurate diagnosis of their problems and finding an approach to treatment that worked?

In my opinion, the extra cost and time required for such an approach are more than justified by the built-in checks and balances as well as the added likelihood of clinical accuracy. The combination of clinician self-discipline and psychological or neuropsychological testing pretty much assures that you will not miss much or over treat the patient. The likelihood of the clinician lapsing into formulaic practice, such as automatically seeing a psychotherapy patient once weekly for many months or even years, is much reduced. In my practice, I frequently see people at non-standard frequencies, such as once every three weeks, and for a limited time period. Many patients do not require long-term psychotherapy at all. My choice of a therapeutic approach, cognitive-behavioral or psycho dynamic, for example, is based on test results and a well-considered diagnosis. Consultation with other experts is used liberally, and collaboration with spouses or family members may also be called for.

The benefits of such a process? Simple. More focused and efficient treatments. The ability to identify patients who cannot really benefit from psychotherapy alone. And, most particularly, results, results, results, as opposed to assertions that what you do works.

Now when someone challenges that what I do is based only on opinion, I am well-armed to respond. I am transformed in their eyes into a "real doctor." I have evidence. And, I do have follow-up.

Steven A. Frankel