Donna Sudak shares her tips for weaving cognitive behavioral therapy (CBT) into the 30-minute psychotherapy session with medication. The article on rating scales she references - Free, Brief, and Validated - is available here.
Published On: 12/14/2020
Duration: 19 minutes, 49 seconds
Article Referenced: "Brief Therapy During the Medication Visit," The Carlat Psychiatry Report, November/December 2020
Today, an interview with Donna Sudak on psychotherapy during the 30 minute med visit.
Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
Kellie Newsome: There are three people in the room during psychotherapy: You, the patient, and the clock. That last player used to be pretty standardized to the 50-minute hour. Therapists saw patients for 50 minutes and used the 10-minute buffer at the end of the hour to reset themselves for the next patient. That all changed in 2013, at least for insured patients in the U.S., when health insurers carved up the hour into 3 types of psychotherapy – brief, medium, and long. Each type has its own billing code, an average duration, and a range that’s allowed around the typical duration:
- Brief sessions are 30 minutes, but can range from 16-37 minutes. They are coded 90833 if added on to a med visit, or 90832 for therapy alone.
- Medium sessions are 45 minutes, but can range from 38-52 minutes. They are coded 90836 in a med visit, or 90834 for therapy alone.
- Long sessions are 53 minutes or more. They are coded 90838 in a med visit, or 90837 for therapy alone.
Some insurers, like United Health Care, only cover the long visit for special circumstances, like doing exposure therapy for OCD or an anxiety disorder, doing dialectical behavior therapy for borderline personality disorder, or when a patient is in an acute crisis that might otherwise send them to the emergency room. Those changes are shifting a lot of therapists toward a 45 minute hour instead of the time-honored 50 minute hour. So you could say the new billing codes have shrunk psychotherapy, but they’ve also expanded the use of brief sessions.
And that was the intent of the change all along – it wasn’t just insurance that drove it. Psychiatrists and psychotherapists were included in the discussion, and they wanted to raise the incentives for psychiatrists to do brief psychotherapy during the med visit. Before the change, it was much more profitable for a psychiatrist or psychiatric nurse practitioner or PA to do two 15-minute back-to-back med visits than a single 30 minute psychotherapy session. But the new therapy add-on codes have caused that difference to shrink, although the exact details depend on which insurance is paying, how much of the 16-37 minute time frame is used, and which E&M code is used for the medication piece.
Donna Sudak believes these changes are good for patients and providers, because we can start to use the more humanistic skills that drew many of us into the field to begin with.
Dr. Sudak: I think most of us who do this got interested in doing this with frustration with the idea that we’d call this a “med check”; you know that you’d leave somehow those particular skill sets at the door and that they couldn’t be helpful in a briefer format. And I think one of the things this enhances - not only I think how patients do, but it also enhances the quality of life of the person who’s practicing because you get to use a lot more of your skill set in the service of helping someone.
Kellie Newsome: In this month’s issue we interviewed Dr. Sudak about brief psychotherapy, and today we’ll play some excerpts from that conversation.
Dr. Aiken: What do you see as the key ways that brief psychotherapy (and when I use that I mean like 30 minutes) differs from the standard 50-minute session)?
Dr. Sudak: What’s different I think is the scope of what you can tackle in a particular 30-minute time frame; how many problems you can take on; and sometimes making decisions about tackling certain things or not tackling certain things if there were the need for more time.
So for example, trauma is one of the things that I can think of that you probably would defer to a longer session simply because you wouldn’t intentionally have enough time to manage the affect that was occurring.
The other thing I think that’s a basic difference is that it really helps to have an organization with respect to the session.
I think that’s one of the reasons that CBT lends itself so well to the briefer time frame because there’s already the expectation between you and the patient that you’re gonna set an agenda; figure out what is the most important thing to talk about; you’re gonna gather information in an efficient way to help you make decisions about what needs to happen; and then very quickly hone in a problem that is going to get resolved.
Dr. Aiken: So more organized and more prioritization. How do you orient the patient as to what to expect in these sessions?
Dr. Sudak: Well, it’s the same as orienting someone to a 50-minute CBT hour. You know it’s letting people know that I sort of have a door rule: so we might talk about the Philadelphia Eagles until we get to the door of my office and then when we open the door of my office the idea is we are gonna get down to business. And if I need to do that I’m just gonna let the patient know that we really want to use the time together in the best way possible so that we can resolve as many things as we can.
I’m going to orient people to the idea that they are going to fill out paper and pencil measures in the waiting room before they come in. I think that is a critical aspect of care in general. We don’t know just how people are doing without doing that. But also, in a briefer session, you’ve already been able to decide are there particular issues based on this measure that I need to attend to that I might need to bring up like, “Oh, your depression inventory has doubled in its severity over the course of the last week; what the heck is going on?” We might want to hone in on that. So it’s gonna give us a place where to start.
And I’m going to explain to people in the first session when we meet the idea that we would want to come into a session with one or two particular things that were coming up in the course of the week that you’d want to address. Sometimes I would bring things up and sometimes they would bring things up, and we would decide together which of those we’d work on.
So it’s really just acculturating someone.
One other thing I think is really important, at least in trainees, is the notion that both people have access to what time it is. I think there ought to be two clocks in the office: the patient should see what time it is; I should see what time it is because it helps people stay much more on track if they’re aware that they only have a minute or two or five minutes left. And I think about this from the standpoint of helping people to segue to particular times in the session by saying, “You know we’ve got about five or ten minutes left; let’s think about what we’ve accomplished today, or let’s wrap things up” making sure that people are aware that we are making those kinds of transitions.
Dr. Aiken: What are your top rating scales, and if they’re free (5 minutes) we’ll put them on line for the readers.
Dr. Sudak: I certainly use the PHQ-9. I use the GAD-7. There’s a great article called “Free, Brief, and Validated” by Rinad Beidas, and it lists a bunch of different scales that you can access in that particular way.
Dr. Aiken: Wonderful reference, thank you. Any other tips you have for making the most of that 30 minutes?
Dr. Sudak: I think that pacing is really an art. In some ways, one of the things that’s a little more complicated about doing this kind of work is having a plan for the session: knowing what you did the last time and what the person took away as out-of-session practice; having a sense of what you want to try to accomplish in this next go-around; what’s been the kinds of problems the person has been bringing up; making sure that you’ve been kind of artfully moving from topic to topic with some summaries so that you’re sure that you and the patient are on the same page; and getting feedback about what the patient is going to take away from the session I think are really, really important because it will help you to understand whether or not the format itself is moving too quickly for the patient to absorb pieces of information that would be important for them to learn.
Dr. Aiken: I hear you that you check in more throughout the session to make sure you are not going too fast.
Dr. Sudak: Yes, absolutely. And the way I would do that is not saying,“Am I going too fast?” because generally what will happen is that the person will say, “Oh no, everything’s fine.” But I might say, “I’m wondering what you learned from what we just discussed? What’s the take-home point?”
And generally speaking, when that take-home point comes about I’m going to ask the person to write it down. That’s a hugely important piece of what I do, I think, is making sure that the person is not just taking away what happens in the session in their head. We know that people forget somewhere around 50-70% of what occurs in the normal physician visit; that’s not even when they’re depressed or anxious. It’s gonna get worse with us. And so anything that I really want the person to absorb and remember needs to be in writing. And some of my patients actually tape my sessions and listen to them again in the future. And I think that that can also be a really helpful adjunct to treatment.
Dr. Aiken: And how do you follow up on homework that you might have assigned without making the patient feel bad if they didn’t do it?
Dr. Sudak: Oh, goodness. Well, homework should always be “no lose.” And the first thing that’s really important is to think about (1) making sure that the person is confident that they can do this thing. So I’m not gonna give somebody something to do that we haven’t done in the session a little ways so that they know they have a sense of confidence about it. The person needs to know that the purpose of doing this – for example, the homework that doesn’t usually get done is when the person is about to leave the office and you say, “Oh I haven’t assigned something; here, just take this sheet and fill it out for next week.” That is never gonna fly. You really have got to have a sense that they know that they can do it; why they are gonna do it. And I like to think about 4 W’s: who, what, when and where, and what’s the reminder system that they’re gonna have about it.
But the important thing is that it has to be the right size. I’m gonna ask folks you know, “Does it make sense to you that this is what you are gonna practice outside of the session and do you see any obstacles to it?” And then if the obstacle comes up we can sort of normalize the fact that that’s the case. Okay, this one didn’t go so well. But if that happens every single week, then part of what I have to talk about is really the purpose of this in the first place. It doesn’t do anybody any good to be a good patient.
Dr. Aiken: Yes, the purpose is really important. So I imagine if you assign for them to go walking every day, you need to know when they are gonna do it, where, and with whom?
Dr. Sudak: Yeah, and I would also ask what could get in the way. And walking every day is pretty ambitious.
(10 minutes) You know I might sort of say, “You know what do you think is a reasonable goal to try out for this week, and do you see any particular obstacles?” And if the person says, “Oh no, of course, I’m gonna walk every single day.” I’d say, “Well, let’s just take a minute and think, you know; have you thought about what you’d do if it was raining?” and “What’s kept you from walking up until now?” Those kinds of action prescriptions are hugely important.
And so the thing that I have to bring up if they don’t is what if you don’t feel like it, right, because that is the thing that is generally what gets people, right, cause the natural tendency of being depressed is that you’re not gonna feel like going. And so we really have to sort of confront that in a more direct way and help the person finds ways to motivate themselves to motivate themselves to do that at that moment.
Dr. Aiken: I imagine by being the one to anticipate good reasons for not doing it, it makes it easier for them to tell you they didn’t do it.
Dr. Sudak: Right, and in addition, I will also normalize the fact that you know sometimes it is a very hard thing to engage in these sorts of activities; where did we go wrong? Is there something about the assignment that didn’t fit? Or was it too big; was it too much or too little? What about it? What got in the way?
So I think that we have to be reasonable about that, but also not relinquish the idea that this is a very important part of treatment.
Dr. Aiken: Still, I wonder with depression being an illness of guilt if it’s still hard to do this right with clients? Despite your best efforts do they end up feeling guilty sometimes about not doing the assignments and how you work around that?
Dr. Sudak: Right, well some of what you’d do is to say, “Well that’s an interesting thought that you’re having about that. And what were you thinking I might be thinking? Are there other possibilities that I might be thinking? You know I could be thinking, you know, I could be thinking well maybe this was just the wrong assignment or maybe we need to sort of take a step back and see what went wrong or other kinds of possibilities there.” And I might also talk about what did they think the purpose of my bringing up the homework was? Was it to help them to feel bad or was it really an effort to try to make this work out better because getting behind doing something would make a difference.
Dr. Aiken: Now that you say that, I realize most of my patients tell me what they think I’m thinking right away. They say, “You’re gonna be mad or you’re gonna be upset.”
Dr. Sudak: Right, exactly, and when that happens I think it’s really cool to say, “Well, that’s an interesting way to think about it. Would there be another possible set of things that I could be thinking at that particular moment.”
Kellie Newsome: In our online edition, Dr. Sudak shares her top tips for using brief therapy in bipolar disorder, OCD, schizophrenia, and anxiety disorders. She also gets into research on how psychiatric medications can enhance – or interfere with – the psychotherapy process and what we can do about that.
Donna Sudak, MD, is Professor and Vice Chair for Education and Drexel University College of Medicine. She is the author of four books on psychotherapy including Combining CBT and Medication: An Evidence-Based Approach.
Dr. Aiken: And now for the word of the day…. The 50 Minute Hour
Kellie Newsome: The 2013 billing codes may have put an end to the 50 minute hour, but where did the idea get its start? We traced it back to 1913. It was a year where clocks were setting the pace all over the globe. They kept the trains on time at Grand Central Station, which opened that year in New York City. Further South, Louis Armstrong kept tight with time as he played his first gig in New Orleans. And factory workers were racing to beat the clock as Henry Ford launched the first successful assembly line in Detroit Michigan and RJ Reynolds rolled out the first packaged cigarettes in Winston-Salem North Carolina.
And in Vienna Sigmund Freud wrote a how-to guide to psychoanalysis, “On beginning the treatment.”
Freud: “In regard to time, I adhere strictly to the principle of leasing a definite hour. Each patient is allotted a particular hour of my available working day; it belongs to him and he is liable for it, even if he does not make use of it. This arrangement, which is taken as a matter of course for teachers of music or languages in good society, may perhaps seem too rigorous in a doctor, or even unworthy of his profession.”
But what if the patient is ill or can’t attend? Freud argued against making any allowances for such interrupts.
Freud: “My answer is no. No other way is practical. Under a less stringent regime the ‘occasional’ non-attendances increase so greatly that the doctor finds his material existence threatened. Whereas when the arrangement is adhered to, it turns out that accidental hindrances to not occur at all and intercurrent illnesses only very seldom.”
Freud believed that many of the illnesses that kept people from attending were psychogenic in origin, and would tend to crop up as a defense just as the psychoanalytic work was gaining momentum. But he also acknowledged that real “organic” illnesses do get in the way of attendance, and in those cases he would end therapy until the illness resolved so that the patient would not be charged.
Freud kept track of the hour with a pocket watch, but his chow chow Jofi was often better at sensing the end of the hour. Freud’s dog was attuned to the non-verbal signals in the room and would rise up in attention as the sessions came to a close.
Freud admitted that he occasionally scheduled patients for more than an hour, such as recalcitrant patients who took a long time to open up and communicate to him. But an investigation of Freud’s actual schedule, which Ulrike May undertook in 2008, revealed the doctor to be much more flexible in his appointments, scheduling several patients for an hour and 15 minutes, and hour and a half, or even 3 hours a day.
Freud saw patients 6 days a week for an hour a day, and though this routine may seem a far cry from the brief sessions we’ve focused on in this podcast, he shared Dr. Sudak’s concern with keeping continuity between the sessions. Brief sessions may be separated by several weeks, but for Freud even the single-day break from analysis was enough to break the pace.
Freud: “Even short interruption have a slightly obscuring effect on the work. We used to speak jokingly of the ‘Monday crust’ when we began work again after the rest on Sunday. When the hours of work are less frequent, there is a risk of not being able to keep pace with the patient’s real life and of the treatment losing contact with the present and being forced into by-paths.”
Freud’s therapy – which asked patients to devote 1 hour a day for several years – was met with skepticism even in the slower-paced world he operated in. A physician and friend challenged him to come up with a “short, convenient, out-patient treatment for obsessional neurosis.” Patient’s wrote Dr. Freud asking if they could convey their history in written form before the session so as to save time and avoid the emotional energy of narrating it to him. Other patients tried to bargain with Freud, asking if him to offer discounted rates for treating only one of their symptoms. “If only you can relieve me from this headache or phobia, I can deal with the other symptoms in my daily life.” But in Freud’s universe, treating one symptom would just cause another to pop up – one day it’s hysterical fainting, the next day it’s shortness of breath or lethargy. All of these symptoms, Freud that, had their origins in unconscious conflict, and unless the slow process of resolving that conflict was undertaken they would just keep returning.
Fifty years later, the same reasoning was used to argue against the use of psychiatric medication. Treating one symptom would just cause another to arise. Take away the panic attacks, and the patient may fall into a depression, treat the depression, and a nervous tic might take its place. That psychoanalytic theory is called symptom substitution – and it’s not one that has held up well over time.
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