DOES A "THERAPEUTIC RELATIONSHIP" MAKE A DIFFERENCE?

One of the reasons that I am not a provider for medical insurance [so my patients have to pay out of pocket for my services] is that reimbursement is very restricted and the medical insurance companies justify this by suggesting that a reasonable and customary amount of time with a patient to help them with their medications is 10-15 minutes. That is not enough time for me to help my patients determine if the medication is helping and if the dose is appropriate. I am convinced that I need to have established a relationship with my patients so that they feel comfortable telling me things and trust my judgement about their medications. This takes more than 10-15 minutes, initially taking 60 + minutes and after that a minimum of 30 minutes. When 30 minutes has been scheduled helping my patients can take longer and I will then add another 15 minutes and even another 30 minutes sometimes. I hesitate to do this if I am scheduled without an immediate break and yet my patients have been understanding if I am running late due to needs of one of my patients as they know that I would spend extra time with them if it were needed.

What if therapeutic relationships with patients is not important to how well they do with medications? There was an article in Psychiatr Serv. 2018 Jan 1;69(1):41-47 by Totura, CMW, et al. entitled "The Role of Therapeutic Relationship in Psychopharmacological Treatment Outcomes: A Meta-analytic Review". This study looked at the role of therapeutic relationships in the delivery of effective psychopharmacological treatment.

The authors reviewed many publication sites looking for articles addressing the above question. They found eight independent studies that were empirically based [involving 1065 patients] in which measures of the therapeutic relationship were administered and psychiatric treatment outcomes were assessed. They found that the overall average weighted effect size for the association between the therapeutic relationship and treatment outcomes was z = .30 indicating a statistically significant, moderate, positive effect of the alliance on outcomes of psychopharmacological treatments. 

So, the above review of 8 studies supports the benefit of a therapeutic alliance [relationship] on the outcome of psychopharmacoloical treatments [treating people who have psychiatric disorders with medication].

I see the benefit everyday in my work with people who come to me.

WHY I DON'T LET INSURANCE COMPANIES TELL ME HOW MUCH I CAN CHARGE FOR HELPING MY PATIENTS

Almost two years ago I decided to not accept the limitations that insurance companies place on what I charge.  Insurance companies reimburse psychiatrists for a brief "medication check."  This often translates into a 10 minute session during which there is discussion of how the person is doing in general, an evaluation of current symptoms and response to the medication, review of any side-effects to the medication, decisions regarding any dose changes or change to a different medication, and finally a plan for evaluating the response to the medication and possible side-effects.   That is a lot to cover in a short amount of time.  I do not believe that it can be done in 10-15 minutes.  It takes more time to cover all of these areas that are important for anyone taking medications.  I have found that this can not be rushed and that improvement is related to the time spent listening and interacting and coming to joint decisions regarding the treatment. This is true whether it is focused on medication or other forms of treatment.

I have also found that the time spent is important to be able to assess the level of stress each person is experiencing and then develop ways to help that person reduce their stress level.  This is very important to overall improvement and is a major factor in increasing positive responses to medication.

I also have seen the importance of making the treatment fit the individual person. This influences the type of medication that I prescribe and allows for a determination of the optimum dose of medication. One size does not fit all. Even if one can guess that based on statistics with large numbers of people a certain dose range is likely to be helpful for any one person, it still makes a difference to discover a specific dose that is helpful for each person.  

Individualizing treatment for each person is also important when evaluating some laboratory [blood test] results, especially those involving hormones such as the thyroid.

All of the above takes time and I will not compromise this to fit reimbursment limits from insurance companies.  I have found that even though it costs more initially to see me, the positive results and improvement lead to a significantly improved quality of life and is worth the investment.

For more about my philosophy of treatment, please see the "PHILOSOPHY" section of this website.