Seeking advice on choosing (or not choose) between a therapist and a psychiatrist.

September 15, 2007 10:24 AM

I need help deciding whether to continue seeing my psychologist (who i really like) and see a psychiatrist (who I also really like) for med management, or see the psychiatrist for both therapy and med management? Also, does anyone have experience with Harvard Pilgrim HMO's mental health benefits?

See several of my recent questions for details but basically last month my boyfriend killed himself in a very shocking way. I was already in need of mental health care, and since then have been receiving it from a psychologist with GP doing med management since the event. However, my medication needs are complex to begin with, and complexified further by the tragedy and trauma of the recent event. I need a psychiatrist and was unable to get an appointment with one until today (nearly five weeks post crisis!). The appointment went well, i thought. this doctor was worth waiting for.

I think my psychologist is great and he's been a great help, and we've recently started discussing and working on the issues that had caused me to think about getting help in the first place, before the death. it's going well and i know i could make progress with him. but i definintely need a psychiatrist and i've found a good one that i clearly connect with, who I can tell would be also very suitable for my needs and a good match in general. he doesn't want to be just a med management doc (he typically provides therapy in addition to med mgmt) but1) said he would do that for me long term if i wanted to continue seeing my therapist and 2) is not pressing me to make any decisions quickly/now about transitioning all my care to him instead of seeing both him and my therapist. However, I can immediately see the benefit in doing just that for a number of reasons -- insurance, financial, simplicity, geography, time management.

But. I'm uncertain and maybe reluctant. I know i'm feeling very attached to my therapist because he was there "at the beginning" and we've started to make real progress, thus a general reluctance to make the switch. no one's forcing me to decide immediately, and i have appointments scheduled this coming week with each. Is there any genuine benefit to continuing to see 2 professionals instead of transitioning all my care to one whom I do feel is very competent to meet all my needs? I'm in stabile but not great mode right now; I don't think I'm at risk for dramatically destabilizing if I were to make a change. But i do feel that it would in some ways be starting over to switch all my care to one, new, person.

I've been in and out of therapy, and on and off of meds, all my life and I've never commited to the process. I really want to do things right this time; one of the last things my boyfriend said to me was that he wanted me to be happy. I've been given the chance to work towards that. Any general words of advice? Comments questions and concerns? Thanks for reading.

posted by Soulbee to health (9 comments total)

My friend is a psychiatrist. She has told me numerous times that psychiatrists receive little training in cognitive behavioural therapy and that, because it isn't really their "thing", they tend not to be abreast of new techniques. She says people should only do therapy through a psychiatrist if they can't afford or accommodate two professionals. YMMV.

I'm sorry for your loss.
posted by acoutu at 10:28 AM on September 15, 2007

I'm not sure there is good advice here, as it really is made up of the skills and abilities of the two professionals.

Having had a time when I had both a psychiatrist and a psychologist... the psychologist was of bigger help. I think meds can be helpful, but I have much more faith in solid cognitive therapy and a lot of psychiatrists are little more than pill machines these days.

I think it is certainly worth "seeing" if you can just do one, but just because you choose to do one doesn't mean you can't go back to two.
posted by Gideon at 10:31 AM on September 15, 2007

It's always good, just in case, to have a separate psychologist and psychiatrist. I say this only because it means you have two medical opinions, and they may sometimes differ. Your therapist and psychiatrist can speak with one another, share information (with your approval, of course), and exchange ideas.

So if you can afford and make time to see both, I'd do so at least for awhile. If you really bond with your psychiatrist, or are dissatisfied with your therapist, you can make a change when you feel it's right.
posted by brina at 10:34 AM on September 15, 2007

i definitely can't afford to see both if my HMO doesn't cover it. I couldn't even afford to see one regularly if I didn't have insurance. I believe they will cover therapy and the psychiatrist for short "med management" appts. I think that the medication issues are so entangled with therapy issues that it might make sense for the person writing the scripts to be giving the therapy. and he's definitely not the pill machine -- he typically ONLY sees patients for whom he can provide both therapy and medication management (he also has hours at the local hospital). Essentially he would make an exception for me if I chose to use him only for med management, because that's not his typical MO. I haven't asked him about his psychological background and what types of therapy he is trained in, but I felt positive coming out of the session, like he would be able to provide me with insight, which is what i need, and he was very quick to agree with me when I said i didn't want to be rushed onto antidepressants just because i had been depressed before the event and am still crying every day. we agreed to start by managing my sleep which has been a major issue and not served properly by the tranqs i'm on. we'll go from there. i know i don't have to make a decision now, i can see both for a little while before something is bound to be triggered at my insurance company. what a pain in the ass. thank god i have insurance. thanks for advice so far.
posted by Soulbee at 11:44 AM on September 15, 2007

one other thing. my therapist currently spends one day a week in the town where I work, and I see him on that day. By December, he will have transitioned all of his hours to a different town which would be a big pain in the butt to get to for me. he warned me of this first thing during our first appt and i wasn't in any place to say nevermind, i'll find someone else. as i said, i really like him, but when he moved completely, it will be a major hassle for me, and i've thought about that...
posted by Soulbee at 12:06 PM on September 15, 2007

In this situation I had both covered, but given that my med situation was straightforward and only required quarterly visits, and the vagaries of insurance, that doesn't say much besides "it's possible." I had a referral and recommendation from my therapist which seemed to help.

The benefits I found in keeping both were: consistency in the talking therapy, having a specialist managing medication, and having an individual I'd have a fairly substantive conversation with but on a less frequent basis providing an additional perspective on things. The only obvious drawback was the cost (it still cost something) and the additional appointment.

Given your situation it seems reasonable to give yourself as much support as you can manage. It's not really the time to be worrying about simplicity, geography, and time management unless you absolutely have to, and unless your financial situation is desperate it might be worth risking a month or two worth of debt finding out how the insurance will pan out (if you can't figure it out in advance and the addition of the psychiatrist's full bill would put you in serious economic trouble I don't know if you really have much choice but to consolidate the service), not to mention getting additional support in this early phase of a really traumatic period of your life.

You have two to three months until the additional obstacle of distance from your therapist enters the picture. Why not give yourself more breathing room and decide you will make a decision something like a month or so before this person moves the practice? You could talk it over more with both professionals, get a feeling for how your med situation is working out, and think out the alternatives (i.e. perhaps your therapist would be willing to have a more infrequent session with you as a transitional measure so you could maintain that continuity).

Good luck.
posted by nanojath at 12:30 PM on September 15, 2007

Also consider talking with your psychologist about telephone sessions. I haven't lived in the same state as mine for almost 4 years, we talk regularly, and all my fears about telephone sessions being less productive than in-person sessions were completely unfounded. I think it's important to stick with someone whom you trust, who understands your history, and with whom you feel truly comfortable.

Some psychs will also discount their fee if you ask them to and may allow you to pay when you can if your insurance won't cover enough of the cost.

Best of luck with everything.
posted by TryTheTilapia at 1:33 PM on September 15, 2007

I see a psychiatrist for both meds and talk therapy. While many psychiatrists do seem to focus mainly or exclusively on the meds, there are some who are quite capable on the talk side of things too. I feel that mine is one of these, and it sounds like you may have found one too. So my experience is limited, but I'd argue against ruling out someone as a talk therapist just because they have an M.D. Furthermore, I think that there can probably be benefits to having the meds and therapy come from the same person--it's seemed to me to be a good idea for my med decisions to be made in consulation with someone who knows me in the talk therapy sense.

That said, as I'm sure you know, "the relationship" is an important part of therapy, and you don't want to throw away a good relationship that you've spent a lot of time and effort on, especially if, as you say, you feel like you're making progress.

So if the money thing turns out to not be an issue, and you have the time, it seems like you'd want to see both at least for awhile. But I'd say that yes, it's probably O.K. to consolidate your treatment with the psychiatrist if that's necessary. Whether or not you should do that anyway I wouldn't pretend to know enough to offer an opinion.
posted by epugachev at 2:08 PM on September 15, 2007

Keep seeing the psychologist, and see the psychiatrist for meds. You might want to have longer appointments or more frequent -- lots of times people see a psychiatrist for just a few minutes at a time, and rarely, if they have a separate therapist. There's no need to make up your mind right now about how it's going to be for ever after. If you veer away from the psychologist, you can always go back later -- and the psychiatrist will still be ready to do the counseling thing if you want him to after however long.

You can also ask the psychiatrist if he'll tell you, after a time, if he thinks you'd be better off getting your therapy from the person doing the prescribing. I once had a doctor who thought it would seem self-serving if he did that, but I don't think that's the norm.

By the way, once you have the right meds, decision-making can be a lot less difficult!
posted by wryly at 2:38 PM on September 15, 2007 [1 favorite]