Developing Psychotherapy Skills and a Practice After Residency

For generations, psychiatrists could expect to have a significant part of their practice devoted to psychotherapy, but in recent decades this has been on the wane. Today, some reports indicate that nearly half of all psychiatrists do not offer psychotherapy.

Forces mitigating against psychotherapy by psychiatrists are many, but most notably the rate of reimbursement for psychotherapy is not at an appropriate level. Young psychiatrists enter practice settings where their skills as psychopharmacologists are more valued, and their opportunities to develop the psychotherapy skills they learned in residency are limited.

Many early career psychiatrists (ECPs) wonder how or whether they should make providing psychotherapy a part of their professional lives. I would argue that you should. Despite the challenges, it can be a rewarding part of a career and is harder to take up later after practice patterns have been firmly established. Additionally, the evidence base for psychotherapeutic treatments is robust and side effects are few. As the leader of the clinical team, psychiatrists are expected to have a familiarity with psychotherapy and be able to help less trained clinicians with their cases.

So how does one develop a psychotherapy practice and expertise after residency? Here are several steps you might consider:

• Make time for therapy cases. Whatever practice setting you are in, you should advocate for time to see patients for psychotherapy at least four hours a week, as it is difficult to grow as a therapist with less.

If you have control of your own schedule, so much the better, but if you don’t, just ask! Make it a part of the employment agreement. Don’t allow yourself to be pigeonholed as the “med doctor.”

You can also consider renting space in someone’s office one evening a week and see therapy patients there. How will you get your therapy patients? In most communities, a psychiatrist that will see therapy cases is a sought-after commodity.

Many patients with psychiatric or medical comorbidities will benefit from having a physician doing their therapy, as we have a broader range of expertise and a generally higher risk tolerance than other therapy providers. We are also adept at knowing when to pursue medical complaints versus watchful waiting.

• Continue to develop your psychotherapy skills. Like many skills acquired during residency, psychotherapy skills are not well developed at graduation, especially since the story arc of a therapy case extends over time periods that are longer than many residents have during training.

Take advantage of classes at meetings, courses at local psychotherapy or psychoanalytic institutes, and self-study. The best way to learn to be an excellent therapist is through supervision. Often group supervision is available.

• Seek the advice of experts. Find the style of therapy you enjoy working in, and take the time to meet with an expert in that area to discuss your cases. The Internet has made fitting a supervisory hour into your schedule easier than it has ever been. There are even supervision groups that meet online. Expect to pay your colleague for their time, and expect that investment to come back to you many times over as you develop the confidence and skill to treat a broader range of patients and your extra value is noticed by referrers, peers, and administrators.

What if you want a practice that is primarily providing psychotherapy? Unfortunately, third-party payors do not pay psychiatrists as much to see therapy cases—even those with accompanying medical issues or medication management—as they do to see higher volumes of patients in psychopharmacology. Many psychiatrists decide not to participate in insurance plans for this reason. In many communities, this strategy is a viable one, with most psychiatrists helping their patients obtain partial reimbursement via out-of-network benefits.

Some clinicians choose to tolerate a lower income to be able to do work they find more interesting. Today there are billing services and technology that make running a small private practice easier than ever. If you are considering this route, take an honest appraisal of yourself, ideally with a mentor who is also a therapist:

• Are you charismatic and outgoing? If so, referrers and patients will gravitate toward you if you are responsive and competent.

• Do you have a specialty area in demand in your community? This can fill a practice even if you aren’t a natural networker.

Clinicians with special expertise in children or adolescents, addictions, couples, borderline personality disorder, postpartum, or other areas that many clinicians find challenging will usually see their practices fill by getting the word out to referral sources about their interest area.

To spread the word about your expertise, give talks to organizations of clinicians in your community and write articles for the local medical or psychotherapy society. Interestingly, talks at national meetings can be less effective at practice building than almost anything local. Also, for practice development purposes, an article in the newsletter of the local medical, psychological, or psychiatric society can be more important than a journal article.

• Do you have a supervisor from residency with whom you get along? Choosing a well-connected supervisor is another good way to get referrals as the individual knows your work intimately and can advocate with his or her network on your behalf.

If you are practicing in the same community, take the person out to lunch. He or she will almost always be happy to help you out. Affiliation with your local psychotherapy or psychoanalytic organizations as well as your psychiatric society is important. Go to talks and dinners and meet people to tell about your interest area and practice.

Also, your flexibility in seeing new patients is a key to growing your practice. Stay late. Come in on the weekends. Get those new patients seen quickly. When they are calling around, they will usually go to the first person who can fit them in.

In summary, please continue to develop your psychotherapy skills as an ECP. It will provide a valuable service to your patients and your community and you are likely to find it professionally gratifying. Get supervision at first, and consider an ongoing supervision. If you want a practice that is primarily psychotherapy, be prepared to take a pay cut or to withdraw from insurance panels and either be really personable and responsive or have an interest area that you promote locally.

I am fortunate to have a career in which I get to see patients, run groups, teach, administer, manage, and plan. Almost invariably, however, the most gratifying hours of my week are spent with psychotherapy patients. Use some of the ideas outlined above, and it can be so for you too. ■