Therapy with a psychiatrist

In modern times, most patients need to see a psychiatrist and a therapist separately — we can do both in one visit.

Psychotherapy is not a lesser treatment you do while waiting for medication to work. For many conditions it is the treatment with the best long-term results, and for others it works best alongside medication. A meta-analysis of studies in depression and anxiety found that adding psychotherapy to medication can sometimes be better than medication alone (Cuijpers et al., 2014). However, the data is clear that most of the time a combination of therapy and medication is usually better than one or another alone.

Why don’t most psychiatrists do therapy anymore? Because in modern times, insurance companies do not reimburse very well for therapy sessions so it is more cost effective for hospitals to bill for 15 minute med management visits instead. As an out-of-network physician, I have the opportunity to practice without the shackles of insurance or the confines of hospital admin telling me how to practice. It allows me to dedicate more time to my patients.

Seeing one clinician for both therapy and medication has practical advantages. I can see how a medication change shows up in your sleep, your mood, and your relationships, and I can tell the difference between a symptom that needs a prescription and one that needs a conversation.

I offer three approaches in my practice, and usually use a combination during sessions. They are different tools, and the right one depends on what you are dealing with and what kind of work appeals to you. Many people use more than one over time.

Cognitive behavioral therapy (CBT)

What it is. CBT is built on the idea that how we interpret events, what we do in response, and how we feel are tightly linked, and that changing the first two changes the third. Sessions are structured. We set an agenda, work on a specific problem, and you practice between sessions, because the change happens in daily life, not in my office.

What the evidence says. A review of 106 meta-analyses concluded that CBT has strong support for anxiety disorders, somatic symptom problems, bulimia, anger problems, and general stress, with good support across many other conditions (Hofmann et al., 2012). It is also the base for several of the most effective targeted treatments I use: exposure and response prevention for OCD, trauma-focused CBT for PTSD, behavioral activation for depression, and CBT for insomnia.

What it looks like. You learn to catch automatic thoughts and test them against evidence, face situations you have been avoiding in small steps, and replace habits that feed the problem. A focused problem often takes somewhere between 10 and 20 weekly sessions.

A good fit if you want concrete skills, a clear plan, and measurable progress, or if your main problem is anxiety, panic, OCD, trauma symptoms, depression, or insomnia.

Psychodynamic therapy

What it is. Psychodynamic therapy looks at the patterns underneath your symptoms: how early relationships shaped what you expect from other people, which feelings you avoid, and why the same situations keep repeating. It is less structured than CBT. You talk about what is on your mind, and we pay attention to what comes up, including what happens between us in the room, because that is often where the patterns show.

What the evidence says. A review of the research found effect sizes for psychodynamic therapy as large as those for other treatments considered evidence-based, and noted that benefits tend to hold or grow after therapy ends, which is less true for some other approaches (Shedler, 2010). A later meta-analysis that specifically tested whether outcomes were equivalent found psychodynamic therapy performed comparably to other established treatments (Steinert et al., 2017).

What it looks like. Sessions are open-ended, usually weekly, and the work can be short-term (several months) or longer, depending on your goals. There are no worksheets, though you will probably notice things between sessions.

A good fit if you understand your problem well intellectually and still feel stuck, you keep repeating the same relationship patterns, you struggle with harsh self-criticism or perfectionism, you feel empty or unsure who you are, or you are working through a loss. It suits many high-achieving people whose symptoms are manageable on the surface and still wear on them underneath.

Mentalization-based therapy (MBT)

What it is. Mentalizing is the ability to understand your own behavior and other people’s in terms of the thoughts, feelings, and needs behind it. We all do it, and we all lose it under stress. In a heated argument, you stop wondering why the other person might be acting that way and start assuming the worst. MBT helps you keep that ability when it matters most: slow down, get curious about what is going on inside you and inside the other person, and stay in the conversation (Luyten et al., 2020).

What the evidence says. MBT was developed by Peter Fonagy and Anthony Bateman for borderline personality disorder. In a randomized trial of outpatient treatment, people who received MBT and people who received structured clinical management both improved, and the MBT group showed steeper gains, including in suicidal and self-harming behavior (Bateman & Fonagy, 2009). Difficulty mentalizing shows up across many conditions, and the approach is now used for relationship problems, attachment and trauma, depression, eating disorders, and with parents and adolescents.

What it looks like. Sessions focus on moments when your understanding of yourself or someone else broke down: a text that felt like rejection, a fight that spiraled, a reaction you cannot explain. We slow those moments down and look at them together. It is practical and focused on right now, not on digging through your childhood.

A good fit if your emotions move fast and feel intense, your close relationships are stormy or exhausting, you often feel misunderstood or are unsure what others mean, or conflict tends to escalate before you can think. It is also useful for couples and parents who want to respond to each other more thoughtfully.

How we decide

In the first sessions we look at the problem, what you have tried, and how you like to work. Some people want a toolkit, and CBT fits. Some want to understand why, and psychodynamic work fits. Some find that the trouble is mostly in how they read and react in relationships, and MBT fits. These approaches overlap more than the labels suggest, and I will not make you fit a method. Often times I utilize a combination of these methods during sessions. If something is not helping after a reasonable trial, we change it.

Frequently asked questions

References

1. Hofmann SG, Asnaani A, Vonk IJJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36(5):427-440.

2. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65(2):98-109.

3. Steinert C, Munder T, Rabung S, Hoyer J, Leichsenring F. Psychodynamic therapy: as efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. Am J Psychiatry. 2017;174(10):943-953.

4. Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009;166(12):1355-1364.

5. Luyten P, Campbell C, Allison E, Fonagy P. The mentalizing approach to psychopathology: state of the art and future directions. Annu Rev Clin Psychol. 2020;16:297-325.

6. Cuijpers P, Sijbrandij M, Koole S, et al. Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. World Psychiatry. 2014;13(1):56-67.