Frequently Asked Questions
- The Profession
- Managed Care
Psychiatrists are trained as medical doctors. After premedical courses in college, they go to the same medical schools as other physicians and surgeons, take the exact same coursework, and are awarded the same MD or DO degree. Psychiatrists then go on to get specialty training for four years after medical school.
Because psychiatrists are fully trained as medical doctors before they obtain specialty training in psychiatry, they are granted prescription-writing privileges by state and federal governments. Their specialty training also includes extended training in psychotherapy, so a psychiatrist might treat patients with medications, with talk therapy, or with a combination of both.
Psychologists follow a different training track. They receive a PhD or PsyD degree from a college or university, and get several years of psychotherapy training in clinical settings. They also receive special training in administering and interpreting psychological testing instruments. Psychologists are not physicians, and are neither trained nor permitted to prescribe medications.
There are other types of training in psychotherapy. Many social workers and marriage/family counselors have some psychotherapy training.
Psychiatry has a long tradition of respecting the privacy of individuals and the doctor-patient relationship. There are guidelines published by the American Psychiatric Association which spell out in some details the ways in which a psychiatrist should protect patient-related information.
There is always pressure to dilute the strength of the therapist-patient privilege. For example, if you expect a third party, such as an insurance company or HMO, to pay for therapy, they will probably expect, in return, that your therapist provide them with some information about your diagnosis, treatment, and progress. Confidentiality is also limited by law (psychiatrists in California are required to report threats made against specific persons by patients) and by ethics (most psychiatrists will disclose personal information if it is necessary to prevent an acutely ill patient from deliberately harming self or others.)
Psychiatrists get their training in a medical environment where those seeking services are generally referred to as "patients." Other types of therapists often refer to the people they treat as "clients." Because one person might receive care from more than one discipline (eg. therapy from a psychologist and medications from a psychiatrist), organizations which provide mental health services will often refer to "consumers" to indicate a person receiving mental health services, whether from a physician, a counselor, or both.
There are many kinds of psychotherapy, and coming up with a single definition is tricky. In general, however, psychotherapy involves using an expressive medium -- usually language -- to explore one's thoughts and feelings with the goal of increasing understanding and mastery of them.
Psychoanalysis is a specific type of psychotherapy, perhaps the mode most commonly stereotyped by the Freudian psychiatrist with the patient on a couch. There are many other kinds of psychotherapy.
HMO, PPO, MCO, oh my!
There was a time when medicine was delivered the same way as other services: you simply paid your doctor for the services you received. Health insurance began to be offered by employers during World War II, when salaries were frozen by law and corporations had to find other enticements to hire or keep key employees. Soon it became commonplace for people to have health insurance and receive reimbursement for most of the cost of health care.
With consumers insulated from the effect of rising costs, health care became increasingly expensive. In an attempt to control costs (or, for the cynical, capture profits) from these escalating costs, managed care organizations (MCOs) were formed. They are largely based on the concept of capitation: paying a health care provider a fixed amount of money to take care of a patient's health care needs.
Under the old fee for service system, doctors had a financial incentive to provide more care. Under managed care, the financial incentive is to provide less.
The original MCO was a health maintenence organization (HMO), where the physicians are either employed by or under contract with the insurer. A preferred provider organization (PPO) is sort of a hybrid -- patients can go to a physician who is not under contract with the insurer, but the patient's out of pocket expenses will be higher.
Start by contacting your employer or insurance company. Under California's mental health parity laws (see below), certain conditions must be treated by the same rules as any other covered medical condition. (This contrasts with past practice, where treatments for mental illnesses were sometimes excluded or severely limited simply because these biologically-based conditions were traditionally classified as "mental" instead of "physical.") Your insurer is required to provide you with access to a specific mental health practitioner appropriate for treatment of your condition -- not just a list of names.
In late 2000, the California legislature passed a law (Assembly Bill 88) that required insurers to cover treatment of certain mental illness on the same terms that they treat diseases outside the brain. This means that they could no longer charge different copayments or place more strict limits on treatment of certain diseases simply on the grounds that they were brain diseases traditionally treated by psychiatrists.
Managed care companies in California are regulated by the Department of Managed Health Care, a unit of the state Business, Transportation & Housing Agency. They are a complaint-driven organization -- if you don't report problems with your managed care company, they won't be able to fix them. In addition to their Web Site, they have a toll-free number: (888) HMO-2219